Double Jeopardy - A Case of Overlapping Takotsubo Syndrome and Spontaneous Coronary Dissection

Acute coronary syndrome (ACS) includes a spectrum of clinical conditions, with increasing recognition of myocardial infarction with non-obstructive coronary arteries (MINOCA). Among its potential etiologies, Takotsubo syndrome (TTS) and spontaneous coronary artery dissection (SCAD) present with overlapping clinical features, posing diagnostic challenges. We present a case of a 56-year-old postmenopausal woman with recurrent chest pain and elevated troponin levels, initially diagnosed with TTS based on apical ballooning and a lack of obstructive coronary artery disease. However, persistent symptoms and echocardiographic wall motion abnormalities prompted further evaluation with cardiac magnetic resonance imaging (CMR), which demonstrated subendocardial late gadolinium enhancement (LGE) in the right coronary artery (RCA) and left anterior descending (LAD) artery territories, raising suspicion for an ischemic etiology. A subsequent coronary angiogram with optical coherence tomography (OCT) confirmed SCAD of the LAD, establishing an overlapping diagnosis of TTS and MINOCA due to SCAD. This case underscores the essential role of the multimodal imaging in refining MINOCA diagnoses and highlights the potential interplay between TTS and SCAD. Further research is needed to clarify their shared pathophysiology and improve diagnostic and therapeutic approaches in similar cases..