ST-Segment Elevation: Hypocalcemia or Takotsubo Syndrome? A Diagnostic Dilemma

A wide range of etiologies, both ischemic and nonischemic, can produce an electrocardiographic pattern of ST-segment elevation (STE), including Takotsubo syndrome (TTS) and electrolyte imbalances. Instances of hypocalcemia-induced TTS and STE are exceedingly rare in medical literature. This paper presents the case of a 75-year-old woman with advanced ovarian cancer and no prior heart issues, who exhibited diffuse STE on electrocardiogram, resembling acute coronary syndrome. Additionally, echocardiography suggested left ventricle apical ballooning, as per TTS, in the context of severe hypocalcemia and elevated troponin I level. After confirming no coronary artery disease via angiography, we administered calcium supplementation. Subsequently, the electrocardiogram displayed widespread giant T-wave inversions, and the patient's cardiac function fully recovered on normalization of calcium levels within few days. This case serves to highlight the importance of recognizing rare causes of STE (eg, hypocalcemia-induced cardiomyopathy), particularly in patients with neoplastic condition. However, the precise mechanism underlying a potential hypocalcemia-induced TTS remains to be elucidated, and there are only a limited number of case reports in the literature. In light of the aforementioned considerations, we propose a comprehensive examination of cases associated with hypocalcemia and STE and left ventricular systolic impairment.