Reverse-Type Takotsubo Cardiomyopathy: A Case Report

Reverse Takotsubo cardiomyopathy (TCM), also known as inverted TCM, is a rare variant of TCM. Typical TCM affects the apex of the heart, while reverse takotsubo affects the base of the left ventricle. Reverse TCM is characterized by basal hypokinesis and apical hyperkinesis. It typically occurs in younger individuals with a higher prevalence in men who have experienced emotional or physical stress. The case presented below is very atypical, considering it occurred in a 74-year-old female. TCM can also be associated with intracranial hemorrhage, anesthesia, or other neurological conditions. Treatment usually entails supportive management, focusing on heart failure therapy and addressing the underlying trigger. Conservative management with beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers can be used to mitigate catecholamine surges and sympathetic overstimulation. Common complications of reverse TCM include myocarditis, effusions, and left ventricular (LV) thrombi. While both forms can be severe, reverse TCM is associated with less hemodynamic compromise and faster recovery, typically marked by a return to normal left ventricular function within a few weeks. A 74-year-old woman with bilateral lower extremity cellulitis and no history of coronary artery disease presented via EMS to the emergency department (ED). The patient complained of chest pain following a verbal and physical altercation. The electrocardiogram en route showed ST elevation, and the patient was administered four sublingual nitroglycerin tablets and 324 mg of aspirin. In the ED, the patient's ECG showed a normal sinus rhythm with right axis deviation, and troponin was elevated. Computed tomography angiography of the chest was negative for pulmonary embolism. The patient was admitted to the medicine service with a cardiology consult. Cardiology suspected TCM, which was confirmed by a left ventriculogram. We discuss the typical presentation of the atypical diagnosis of TCM. Of the atypical forms of the disease, the most common is reverse TCM. The clinical manifestation often mimics acute coronary syndrome with chest pain, elevated cardiac biomarkers, and ECG changes, but coronary angiography usually reveals no significant obstructive findings. This case report highlights the importance of maintaining a broad differential diagnosis in patients presenting with chest pain and of recognizing those at risk for TCM.