Takotsubo Syndrome Mimicking Non-ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock: A Case Report

Abstract

Background: Takotsubo syndrome (TTS) is a transient, stress-induced cardiomyopathy that clinically mimics acute coronary syndrome (ACS). Early diagnosis using established clinical scoring systems and imaging is essential to optimise acute management and avoid inappropriate long-term coronary therapies. Case Presentation: A 70-year-old woman presented to the cardiac care unit with chest discomfort, palpitations, and severe anxiety 24 hours after an acute emotional stressor. On admission, she was  hypotensive (blood pressure 80/60 mmHg), with a pulse rate of 58 beats per minute, consistent with cardiogenic shock. Initial laboratory investigations showed elevated cardiac troponin I (3,752 pg/mL)                   and N-terminal pro-B-type natriuretic peptide (23,756 pg/mL) concentrations. The initial electrocardiogram (ECG) demonstrated an anteroseptal ischaemic pattern that mimicked a non-ST-elevation myocardial infarction (NSTEMI). The patient had a documented history of long-standing paroxysmal atrial fibrillation (AF); during the first four days of admission, serial ECG monitoring documented an acute episode of AF with a rapid ventricular response, together with low-voltage complexes and deep inferior T-wave inversions. Transthoracic echocardiography (TTE) demonstrated classic apical ballooning with severe hypokinesia of the apical segments, right ventricular systolic dysfunction, and severe eccentric mitral regurgitation (MR) secondary to underlying myxomatous posterior mitral leaflet prolapse. Emergency coronary angiography revealed non-obstructive coronary artery disease, ruling out acute myocardial infarction. The InterTAK Diagnostic Score was 72, indicating a high probability of stress cardiomyopathy. Management included tailored inotropic and vasopressor support, fluid optimisation, loop diuretics, and oral anticoagulation. The patient was discharged in a stable condition on Day 5. At the 2-week follow-up, repeat TTE showed normalisation of biventricular systolic function, resolution of the regional wall-motion abnormalities, and a return of MR to its chronic mild baseline. Conclusion: This case highlights the clinical value of using the InterTAK score alongside multimodality imaging to differentiate suspected acute coronary syndrome mimics. The documented complete structural recovery within 2 weeks provides clinically relevant information on TTS presenting with multiple complications.