A Case of Acute Coronary Syndrome in Disguise

Abstract A 56–year–old Caucasian woman with a silent cardiac history, a history of smoking, and a previous hip prosthesis surgery presented to the emergency department. She reported oppressive chest pain radiating to the left arm intermittently for about 2 days, precipitated by significant emotional stress at work. The 12–lead ECG revealed sinus bradycardia, symmetrically negative T waves in the anterolateral leads, and prolonged QTc interval (544 ms). The echocardiogram showed apical akinesia, basal hyperkinesia, and moderately depressed global systolic function (ejection fraction 45%). Laboratory tests indicated elevated myocardial necrosis enzyme levels (hs–TnI 549 pg/ml), negative inflammatory markers, normal electrolytes, hemogram within normal limits, and normal renal function. She was admitted with a working diagnosis of NSTEMI–ACS. On admission, the patient was asymptomatic for angina, and had stable vital signs, particularly a blood pressure of 120/70 mmHg and a heart rate of 55 bpm. Clinical examination revealed no abnormalities. The InterTAK score was 67. Coronary angiography revealed severe stenosis of the mid–left anterior descending coronary artery, treated with PTCA–DES. The intracoronary imaging (OCT) showed a plaque with characteristics of stability, leading to the consideration of the diagnosis of Takotsubo syndrome in patient with CAD. Subsequent echocardiography showed nearly complete recovery of systolic function. At the one–month follow–up, the patient exhibited preserved systolic function (EF 60%). This case highlights Takotsubo syndrome with concomitant coronary artery disease (CAD) as a bystander. According to Mayo Clinic criteria, the coexistence of severe CAD would exclude the diagnosis of Takotsubo. However, recent studies suggest the potential for coexistence, prompting the need for additional imaging modalities such as OCT and CMR to differentiate culprit from bystander lesions. Utilizing these techniques may alter the prevalence of Takotsubo syndrome, necessitating a reassessment of cases initially classified as NSTEMI–ACS.