Background: The original case series of patients with Takotsubo Syndrome (TTS) reported no significant epicardial coronary artery disease during angiography. However, recent evidence suggests an increasing overlap between the two diseases. We report a case of a 48-year old woman who had untreated generalized anxiety disorder and presented with angina.
Case: A 48-year old woman with untreated general anxiety disorder presented with a 5 hour history of angina. An electrocardiogram demonstrated a prolonged QTc, no ST segment changes and new T-wave inversions in the anterolateral leads. High-sensitivity troponin was 4,336 ng/L and her InterTAK score was 91 with a 99.6% probability of TTS.
Decision-making: Due to her persistent chest pain and EKG changes the patient underwent emergent left heart catheterization which showed critical occlusion of the 1st diagonal and 71% stenosis of the distal left circumflex. She underwent a primary PCI of both lesions. Her chest pain resolved after 6 hours of a nitrolgycerin infusion postoperatively and a transthoracic echocardiogram showed hypokinesis of the mid-distal apical, periapical, septal, lateral, inferior and anterior wall with an ejection fraction of 30-35%. The distribution of hypokinesia was out of proportion to the territory supplied by the culprit artery, suggesting a possibility of the apical type of Takotsubo syndrome. She was started on guideline-directed medical therapy for heart failure with reduced ejection fraction and dual antiplatelet therapy
Conclusion: Patients with TTS may have coexistent significant epicardial CAD. Prolonged QTc and lack of ST-segment elevation in patients with CAD may help identify an additional diagnosis of TTS
