A Rare Case of Takotsubo Cardiomyopathy Recurrence With Alternate Reverse Phenotypes

BACKGROUND Takotsubo cardiomyopathy (TCM) is a stress-induced cardiomyopathy characterized by transient left ventricular systolic dysfunction and reversible regional wall-motion abnormalities extending beyond the distribution of a single coronary artery. Atypical variants of TCM's classic apical ballooning pattern include mid-ventricular, focal, and reverse TCM. Reverse TCM, defined by basal and mid-ventricular akinesis with relative preservation or hyperkinesis of the apical segments, is uncommon (~2%). Recurrent TCM is rare, and phenotypic switching between different variants in the same patient is exceedingly unusual, posing diagnostic and clinical management challenges. CASE REPORT A 61-year-old woman with a history of apical TCM presented with acute epigastric pain, severe nausea, and vomiting. Laboratory evaluation revealed leukocytosis, and mildly elevated troponin. Electrocardiography demonstrated normal sinus rhythm without acute ischemic changes. Echocardiogram revealed basal-to-mid left-ventricular hypokinesis with apical sparing and LV ejection fraction 40%. These findings were consistent with reverse TCM, likely precipitated by a physiologic stress response related to intractable gastrointestinal symptoms. During a similar hospitalization 1 year earlier, she had been diagnosed with apical TCM following coronary angiography. This is a rare example of recurrent TCM with phenotypic switching between the classic/apical and reverse variants. CONCLUSIONS This case underscores the heterogeneity of TCM presentations and highlights the importance of recognizing atypical variants, particularly in patients with recurrent disease. Phenotypic switching, while rare, should be considered in patients presenting with troponin elevation and non-coronary patterns of wall-motion abnormalities. Careful clinical assessment, awareness of characteristic features, and use of serial echocardiography or other cardiac imaging modalities are essential to establish diagnosis, guide management, and avoid unnecessary invasive testing.