Takotsubo cardiomyopathy in endurance athletes: Clinical insights from marathon-related cases

Background: Takotsubo cardiomyopathy (TTC), or stress-induced cardiomyopathy, is characterized by transient left ventricular dysfunction often triggered by emotional or physical stress. Although classically associated with postmenopausal women under psychological stress, cases among endurance athletes, particularly marathon runners, have emerged, suggesting a unique pathophysiological link between extreme exercise, catecholamine surge, and microvascular dysfunction. Objective: This review synthesizes published cases and mechanistic studies of TTC occurring in endurance athletes, emphasizing marathon-related presentations, diagnostic challenges, and clinical implications. Methods: A structured literature review of PubMed, Scopus, and Web of Science identified case reports and series meeting predefined diagnostic and methodological criteria. Dual extraction, quality appraisal, and PRISMA-guided selection were performed. Results: A total of 42 documented cases were analyzed. The majority occurred in middle-aged athletes, predominantly female, with acute chest pain or dyspnea immediately after race completion. Troponin elevations were modest, and coronary angiography was negative for obstructive lesions. Echocardiography and cardiac MRI typically demonstrated apical or mid-ventricular ballooning with rapid recovery. Mechanistic data support transient catecholamine-mediated myocardial stunning and microvascular dysfunction as central features. Conclusion: TTC in endurance athletes represents a distinct clinical entity within the spectrum of stress cardiomyopathies. Recognition of this condition is crucial in differentiating it from acute coronary syndromes and preventing recurrence through risk modification and psychological or autonomic management.