Delayed onset Takotsubo syndrome following exercise ECG: a case report

Takotsubo syndrome usually occurs immediately following a physical or emotional trigger. In some cases, a triggering stress may not be evident. A delayed manifestation of the syndrome may account for such cases.

An asymptomatic 69-year-old woman presented for a routine cardiac check-up, which revealed normal electrocardiogram (ECG), echocardiography, and exercise ECG. She did not complain of any chest pain during or immediately after the tests. After about 24 h, she developed chest pain for which she was admitted with the provisional diagnosis of acute coronary syndrome. ECG showed dynamic T-wave changes with QTc prolongation. Cardiac biomarkers were mildly elevated. Characteristic reversible left ventricular dysfunction in absence of coronary stenosis ultimately led to the diagnosis of Takotsubo syndrome.

Our case represents a delayed occurrence of Takotsubo syndrome triggered by a treadmill exercise stress test, which manifested about 24 h following the stressor. Such delayed manifestation may account for those cases of Takotsubo syndrome where no immediate triggering stressor is evident.