Rare Case of Second Recurrence of Takotsubo Cardiomyopathy With Variable Ballooning Pattern

BACKGROUND Takotsubo cardiomyopathy (TCM) is a transient form of myocardial dysfunction often precipitated by emotional or physical stress with characteristic apical ventricular ballooning pattern on echocardiogram with no acute coronary event. Recurrent TCM is rare, only occurring in approximately 1-6% of cases, with re-recurrences being even more unusual. We describe a rare case of a second recurrence of TCM in a patient with chronic anxiety but no clear inciting physical or emotional stressors. CASE REPORT A 71-year-old woman with recurrent TCM episodes (2013, 2016) and chronic anxiety presented with chest pain, nausea, diaphoresis, and elevated troponins with a normal EKG and coronary angiography that revealed no signs of significant coronary disease. Transthoracic echocardiogram was notable for mildly reduced left ventricular ejection fraction associated with circumferential hypokinesis and mild left ventricular outflow tract (LVOT) gradient consistent with her second recurrence of TCM. The mid-ventricular ballooning pattern differed from her prior patterns of TCM. CONCLUSIONS This case highlights the importance of clinical suspicion of re-recurrent TCM despite its rarity, especially as it may occur in the absence of clear triggers. Recurrence risk is likely higher in patients with a history of psychiatric conditions, suggesting that optimizing psychiatric care, including psychotherapy and pharmacological management, could be key to preventing further episodes. Although beta-blockers are commonly used for recurrence prevention, their effectiveness may be limited in some patients, particularly those with hypotension or orthostasis. Further research is needed to better understand the mechanisms underlying TCM recurrence and to refine preventive strategies.