Coronary Embolism: A Rare Complication After Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TTC) is a transient stress-induced cardiomyopathy characterized by reversible left ventricular (LV) systolic dysfunction that mimics acute coronary syndrome. Although most patients recover ventricular function, severe LV dysfunction may result in LV thrombus formation and systemic embolization. Coronary embolism is an exceptionally rare complication of TTC and may present as ST-elevation myocardial infarction (STEMI). We report a rare case of coronary embolism complicating TTC in a patient with multiple thromboembolic risk factors. A 74-year-old woman with chronic obstructive pulmonary disease, tobacco use, dyslipidemia, generalized anxiety disorder, and a history of unprovoked deep vein thrombosis and pulmonary embolism on apixaban presented with chest pain and dyspnea two days after cataract surgery. Apixaban had been withheld for three days preoperatively. Electrocardiography demonstrated inferior and anterolateral ST-segment elevation, and cardiac biomarkers were markedly elevated. Emergent coronary angiography revealed embolic occlusion of the distal obtuse marginal branch without obstructive coronary artery disease, requiring thrombectomy and balloon angioplasty. Left ventriculography demonstrated classic apical ballooning with an LV mural thrombus, while transthoracic echocardiography showed an ejection fraction of 15-20% with severe global wall-motion abnormalities. The patient was diagnosed with TTC complicated by LV thrombus and coronary embolism and was treated with dual antiplatelet therapy, anticoagulation, guideline-directed medical therapy, and a wearable cardioverter-defibrillator. This case illustrates the diagnostic challenge posed by the overlapping presentation of TTC and coronary embolism. Severe LV dysfunction, apical akinesis, perioperative interruption of anticoagulation, prior venous thromboembolism, tobacco use, and a newly identified pulmonary nodule likely contributed to a multifactorial hypercoagulable state. Unlike the typical mechanism in which embolization occurs during recovery of ventricular function, coronary embolism developed during the acute phase of TTC. This case also highlights the importance of evidence-based perioperative management of direct oral anticoagulants to minimize thromboembolic risk in high-risk patients. Coronary embolism is a rare but potentially fatal complication of TTC. Early recognition, prompt coronary intervention, anticoagulation, and multidisciplinary management are essential to optimize outcomes. Careful perioperative anticoagulation planning and further research are needed to better identify patients at highest risk for thromboembolic complications and to refine preventive strategies.