Takotsubo cardiomyopathy with rapid left ventricular recovery unmasking asymptomatic but significant coronary artery disease: a case report

(2025) 19:574 Elzain et al. Journal of Medical Case Reports https://doi.org/10.1186/s13256-025-05645-w Journal of Medical Case Reports Open Access CASE REPORT Takotsubo cardiomyopathy with rapid left ventricular recovery unmasking asymptomatic but significant coronary artery disease: a case report Hassan Elzain1* , Mohamed Nadir Mahmoud Karar2, Mohamed Adel Mostafa3, Jasem H. Redha3, Anas Bedawi Babiker3 and Nader Alasousi3 Abstract Background Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a transient cardiac condition characterized by acute but reversible left ventricular dysfunction, typically triggered by emotional or physical stress. While Takotsubo cardiomyopathy usually occurs in the absence of significant coronary artery disease, its coexistence with severe coronary artery disease is uncommon and presents diagnostic and therapeutic challenges. Case presentation We report the case of a 56-year-old Asian woman with a history of hypertension and diabetes who presented with acute chest pain following an intense emotional and physical altercation. On admission, she was hemodynamically stable, with electrocardiogram showing minor ST-segment elevation in the anterior leads and modest troponin rise. Bedside echocardiography revealed apical akinesia suggestive of Takotsubo cardiomyopathy. Coronary angiography demonstrated high-risk multivessel coronary artery disease, including significant left main disease. Cardiac function rapidly improved within 5 days, with normalization of left ventricular ejection fraction and global longitudinal strain, consistent with Takotsubo cardiomyopathy. Given her refusal of coronary artery bypass grafting, percutaneous coronary intervention to the left main and left anterior descending was successfully performed. She was discharged home on optimal medical therapy in stable condition. Conclusion This case highlights the diagnostic complexity when Takotsubo cardiomyopathy coexists with severe coronary artery disease. It emphasizes the importance of considering Takotsubo cardiomyopathy in patients with acute chest pain even in the presence of significant coronary lesions, as Takotsubo cardiomyopathy may unmask otherwise silent but clinically important coronary artery disease. Keywords Takotsubo cardiomyopathy, Coronary artery disease, Stress-induced cardiomyopathy, Left ventricular dysfunction, Percutaneous coronary intervention, Left main disease *Correspondence: Hassan Elzain 1 Sudan Medical Specialization Board, Al Khurtum, Sudan 2 Letterkenny University Hospital, Letterkenny, Ireland 3 Kuwait Ministry of Health, Kuwait City, Kuwait Introduction Takotsubo cardiomyopathy (TC), also known as stressinduced cardiomyopathy or “broken heart syndrome,” is characterized by transient left ventricular dysfunction typically triggered by acute emotional or physical stressors. It predominantly affects postmenopausal women and classically presents with an apical ballooning pattern of the left ventricle, although midventricular and basal © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. Elzain et al. Journal of Medical Case Reports (2025) 19:574 variants have also been reported [1, 2]. TC has diverse clinical presentations and outcomes, ranging from mild symptoms to severe complications, highlighting the importance of early recognition and management [3]. Differentiating TC from acute coronary syndrome (ACS) can be challenging, particularly in patients with coexisting significant coronary artery disease (CAD), due to overlapping clinical presentations and cardiac biomarker elevations [4, 5]. Importantly, TC can unmask underlying asymptomatic but significant CAD, potentially necessitating revascularization [6, 7]. Case presentation The patient was a 56-year-old Asian woman with a history of hypertension and diabetes, managed with metformin. She had been asymptomatic prior to presentation, with no reports of chest pain during her daily activities, no shortness of breath (SOB), and no paroxysmal nocturnal dyspnea (PND). She works as a customer service representative at a telecommunication company. The patient experienced chest pain described as a pressure-like sensation. The pain began immediately after an emotional and physical altercation with a customer, who struck her and pushed her to the ground, causing her to hit the back of her head. She did not lose consciousness and arrived at the emergency department shortly afterward. Page 2 of 6 On examination, the patient was alert, distressed, and hemodynamically stable. Cardiovascular and respiratory exams were unremarkable. A superficial occipital hematoma was noted without neurological deficits. Initial electrocardiogram (ECG) performed upon admission (Fig. 1) showed small ST-segment elevation in the anterior leads, not fulfilling the criteria for STelevation myocardial infarction (STEMI). Serial troponin measurements revealed an initial level of 0.1 ng/mL, rising to 0.6 ng/mL after 2 hours, and peaking at 1.9 ng/mL on the second day. Other investigations, including complete blood count (CBC), renal function tests, lipid profile, and chest X-ray, were unremarkable. Bedside echocardiogram (limited scan) performed in the emergency department revealed akinesia of the apex. Consequently, the patient was shifted to the catheterization laboratory, where coronary angiography showed significant left main stenosis (~50–70%), diffuse left anterior descending (LAD) disease with critical narrowing in the mid and distal segments, and proximal LCx stenosis (~70–80%) with mild distal disease. The RCA showed diffuse atherosclerotic changes but no critical stenosis, maintaining thrombolysis in myocardial infarction (TIMI)-3 flow (Video 1). The findings were consistent with high-risk multivessel coronary artery disease, and the patient was subsequently planned for coronary artery bypass grafting (CABG) after heart team discussion. Fig. 1 Electrocardiogram at the time of admission showing sinus tachycardi (...truncated)