Beyond the Apex: A Case Series of Mid-ventricular Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TCM), also known as stress-induced cardiomyopathy, is characterized by transient, reversible left ventricular systolic dysfunction in the absence of obstructive coronary artery disease (CAD). It can mimic acute coronary syndromes, posing diagnostic challenges that require a high index of suspicion. We present two cases of mid-ventricular TCM, each triggered by distinct acute physical stressors. The first case involves a 63-year-old male with a history of cerebrovascular accident and nicotine dependence who presented following a generalized tonic-clonic seizure. His electrocardiogram demonstrated ST-segment elevations in the inferolateral leads, and laboratory workup revealed elevated cardiac biomarkers. Coronary angiography showed mild non-obstructive CAD, while echocardiography revealed mid-ventricular regional wall motion abnormalities with an ejection fraction (EF) of 35-40%. He was treated with beta-blockers, angiotensin receptor blockers, aspirin, and statin therapy, with complete recovery of cardiac function on follow-up. The second case involves a 66-year-old female with a history of asthma, obstructive sleep apnea, and prior breast cancer who developed acute hypoxic respiratory failure following hashish inhalation. She presented with chest pain and elevated troponin levels, but without ST-segment elevation. Echocardiography showed mid-ventricular wall motion abnormalities and a reduced EF of 30-35%, while coronary angiography demonstrated no significant obstructive disease. Her presentation was consistent with mid-ventricular TCM secondary to acute hypoxemia and physical stress. These cases highlight the diagnostic variability and clinical spectrum of TCM, emphasizing the need for early recognition of atypical variants. Awareness of mid-ventricular presentations is essential for prompt diagnosis, appropriate management, and prevention of recurrence in patients presenting with acute cardiac dysfunction without significant coronary obstruction.