One Patient: Two Variants of Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TCM) is a form of non-ischemic cardiomyopathy that can present with signs of heart failure and volume overload; it often mimics acute coronary syndrome. It is characterized by stress-induced transient left ventricular (LV) dysfunction. Echocardiography classically demonstrates LV apical ballooning and akinesis in typical TCM, although other less common variants exist. Patients typically present with one variant. A 32-year-old woman with a past medical history of alcohol use disorder, anxiety, and hypertension presented to the hospital with chest pain, shortness of breath, nausea, vomiting, and diarrhea. She was diagnosed with cardiogenic shock in the setting of a newly identified LV ejection fraction (EF) of 24% on echocardiogram with findings consistent with typical apical TCM. Ischemic workup was unremarkable, and she was medically managed with clinical improvement and subsequent recovery of cardiac function. Four months later, the patient presented with similar symptoms at which time she was found to have a recurrence of heart failure with reduced LV EF; echocardiography showed reverse TCM. Patients with TCM who develop a recurrence typically maintain the same variant. The recurrence of TCM in a single patient with different anatomical variants is rare and poorly understood. We presented a case of a patient with alcohol use disorder who developed a recurrence of TCM with two anatomical variants. Further studies are necessary to investigate the predictors of recurrence and better understand the underlying mechanisms behind the different variants.