A 58-year-old post-menopausal woman with a 10-year history of systemic hypertension presented with intermittent left shoulder pain and progressive dyspnea (NYHA class IV) for 3 days. There was no fever, palpitations, pedal edema, cough, or oliguria. A significant recent emotional stressor in the form of bereavement was noted.
On examination, she was tachycardic (pulse 110/min), with a blood pressure of 130/70 mmHg and SpO₂ of 94% on room air. Cardiovascular and respiratory examinations were otherwise unremarkable.
ECG showed T-wave inversions in leads I, aVL, and V2–V6, with positive troponin I. Echocardiography demonstrated moderate LV systolic dysfunction (EF 41%) with akinesia involving the mid and distal interventricular septum, apex, and apical, inferior, and lateral walls.
In view of the ACS-like presentation, she was initially managed according to an ACS protocol with dual antiplatelet therapy, statin, and heparin. Coronary angiography performed on 02/09/2026 revealed normal epicardial coronary arteries. In the setting of recent emotional stress and the characteristic regional wall-motion abnormalities, a diagnosis of Takotsubo cardiomyopathy was made.
She was subsequently managed with supportive and heart-failure-directed therapy, including sacubitril/valsartan, a beta-blocker, and an SGLT2 inhibitor. Her symptoms improved and she remained clinically stable.
She was discharged with advice regarding salt and fluid restriction, avoidance of strenuous activity and air travel for one month, and repeat echocardiography after one month.
Normal epicardial coronaries – Coronary Angiography
Takotsubo cardiomyopathy, also known as “broken heart syndrome,” derives its name from takotsubo, the Japanese term for an octopus trap. The characteristic apical ballooning of the left ventricle resembles the shape of this traditional pot.
The pathophysiology is thought to involve acute catecholamine-mediated myocardial stunning following intense emotional or physical stress, with coronary microvascular dysfunction and abnormal myocardial adrenergic signalling contributing to transient ventricular dysfunction. The marked predominance in post-menopausal women has been attributed, at least in part, to loss of the cardioprotective effects of estrogen after menopause.
Takotsubo cardiomyopathy can closely mimic acute coronary syndrome, particularly in post-menopausal women presenting after significant emotional or physical stress. Initial management therefore appropriately follows an ACS pathway until coronary occlusion is
excluded. Once Takotsubo cardiomyopathy is established and obstructive coronary disease has been excluded, treatment is primarily supportive and directed toward LV dysfunction and its complications. Long-term antiplatelet therapy is not routinely indicated unless there is another indication for its use.
Although usually reversible, Takotsubo cardiomyopathy may cause significant acute complications. These include acute heart failure and pulmonary edema, cardiogenic shock, ventricular arrhythmias, left ventricular outflow tract obstruction, and left ventricular thrombus with systemic thromboembolism. Atrial arrhythmias and, rarely, ventricular rupture have also been reported.
LV systolic dysfunction and regional wall-motion abnormalities generally recover substantially over days to weeks, with many patients achieving near-complete recovery. Nevertheless, the acute phase may be associated with significant morbidity and mortality because of heart failure, arrhythmias, cardiogenic shock, or thromboembolic complications. Recurrence occurs in a minority of patients and may follow subsequent emotional or physical stress. Follow-up echocardiography is therefore important to document recovery of LV function and wall-motion abnormalities.
This case highlights the importance of considering Takotsubo cardiomyopathy in
post-menopausal women presenting with an ACS-like syndrome, particularly following acute emotional stress. Recognition of this condition allows appropriate initial ACS management, followed by supportive and heart-failure-directed therapy once coronary disease has been excluded, while avoiding unnecessary long-term antiplatelet therapy and ensuring follow-up of ventricular recovery.
Dr. Arjun Swaminathan, DNB Internal Medicine Resident Kauvery Hospital, Chennai.
Dr. A Ashwin Subramaniam, Senior Consultant Internal Medicine and Academic Director Kauvery Hospital, Chennai.
Dr Srikumar, Senior Consultant Cardiologist Kauvery Hospital, Chennai.
