Takotsubo Syndrome Preceding the Index Event: A Dangerous Clinical Setting

Abstract We describe the case of a 68–year–old patient who presented to the Emergency Department following an unwitnessed syncopal episode with slow recovery of consciousness. On admission, the patient had dyspnoea together with physical signs of pulmonary congestion. Cardiac ultrasound showed severe left ventricular dysfunction with an ejection fraction of 30%, and apical and paraapical akinesis. The admission electrocardiogram showed sinus tachycardia and diffuse repolarization abnormalities, hs TnI was elevated and BNP vl blood gas analysis were unremarkable. During observation in the Emergency Department, the patient experienced epileptic seizure, promptly resolved by intravenous Midazolam. Contrast–enhanced chest CT ruled out aortic dissection disclosing a clinically irrelevant subsegmental pulmonary embolism. A non–contrast CT scan of the brain yielded negative results. In consideration of the atypical clinical presentation and scattered evidence of an acute coronary syndrome, the patient was admitted to our Cardiac Intensive Care Unit (CICU) for additional diagnostic workup delaying coronary angiography in the presence of stable TnI elevation. Three hours after admission the patient continued showing altered consciousness and a subsequent brain CT was performed, demonstrating an intraparenchymal hemorrhagic spreading. Repeat ECGs showed precordial T wave inversion and prolongation of the QT interval. These data, together with LV apical dysfunction, raised the suspicion of Takotsubo syndrome secondary to an acute cerebrovascular event. During the hospital stay, recovery of consciousness, spontaneous absorption of the cerebral hemorrhagic spread and complete recovery of left ventricular function at repeat cardiac ultrasound examinations were observed, confirming the almost unequivocal diagnosis of Takotsubo syndrome. The patient was discharged uneventfully and was scheduled for an outpatient coronary CT scan. This case underscores the crucial importance of a thorough clinical assessment in the management of complex patients in the presence of nonunivocal clinical signs and misleading blood test and imaging data. Moreover, Takotsubo syndrome is a protean clinical entity that can precede the index event as in our patient, i.e. cerebral hemorrhage. Misclassification of these patients as having an acute coronary syndrome could have led to the initiation of antithrombotic therapy, with potential fatal outcomes for the patient.