When the Beat Breaks the Heart: A Case of Arrhythmia-Induced Mid-ventricular Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TTC) is a transient and reversible form of left ventricular systolic dysfunction that often mimics acute coronary syndrome and is usually precipitated by emotional or physical stress. We describe an unusual presentation of mid-ventricular TTC in which ventricular arrhythmia was the dominant clinical feature and a probable precipitating factor. A 71-year-old woman presented with left shoulder pain and palpitations in the absence of chest pain or an identifiable emotional stressor. Initial electrocardiography demonstrated frequent runs of rapid non-sustained ventricular tachycardia, with a markedly elevated troponin I level of 2188 ng/L. Coronary angiography showed unobstructed epicardial coronary arteries with delayed contrast clearance. Cardiac magnetic resonance imaging revealed severe left ventricular systolic dysfunction (left ventricular ejection fraction (LVEF) 20%-25%) with isolated mid-ventricular akinesia and preserved basal and apical contractility, consistent with a mid-ventricular variant of TTC. Management focused on arrhythmia control and supportive heart failure therapy, with acute stabilisation using intravenous amiodarone followed by beta-blockade with bisoprolol and guideline-directed medical therapy. The ventricular arrhythmia resolved, and left ventricular systolic function improved significantly, with follow-up cardiac magnetic resonance imaging demonstrating recovery of LVEF to 50%. Device therapy was not pursued, given the reversible nature of TTC. This case highlights ventricular arrhythmia as both a presenting manifestation and a possible trigger of TTC and emphasises the importance of considering atypical variants in patients presenting with unexplained cardiomyopathy and ventricular arrhythmias. Multimodality imaging remains essential for accurate diagnosis and for guiding appropriate management in such cases.