Takotsubo syndrome was believed to be a rare acute cardiac event until recently with takotsubo cardiomyopathy being its most commonly recognized and often the diagnostic feature. Its diagnosis is becoming increasingly common with varied clinical manifestations most of whom have favorable clinical outcomes, yet it can be associated with life-threatening complications. We report a case of takotsubo syndrome leading to complete heart block which is a unique complication of an otherwise self-resolving disease.
Takotsubo syndrome as a cardiomyopathy is a distinct form of nonischemic cardiomyopathy characterized by abrupt onset transient regional dysfunction [
This is a 73-year-old Caucasian female with history of hypertension and irritable bowel syndrome who presented to the hospital due to sudden onset retrosternal, squeezing, nonradiating chest heaviness during an episode of diarrhea. The pain was associated with minimal shortness of breath. She received aspirin 325 mg by EMS along with sublingual nitroglycerin. On examination in the emergency room, she had a blood pressure of 115/64 mm Hg, a regular heart rate of 67 beats per minute, a respiratory rate of 18 breaths per minute, and saturating 97% on room air. She had normal breath sounds and heart sounds on examination. She was started on nitroglycerin infusion, after which her chest heaviness partially improved but persisted. Initial EKG showed no acute changes but prolonged PR interval of 324 milliseconds (Figure
EKG on presentation showing sinus rhythm with prolonged PR interval.
The patient was known to have a history of prolonged PR interval noted on prior EKGs. Initial labs showed serum sodium 136 mmol/L, potassium 4.1 mmol/L, bicarbonate 22 mmol/L, chloride 102 mmol/L, BUN 42 mg/dL, creatinine 1 mg/dL, glucose 118 mg/dL, calcium 8.7 mg/dL, white cell count 7.3/nL, hemoglobin 12.1 g/dL, and platelet count 219/nL. Coagulation profile and hepatic function panel were also within normal limits. Initial troponin was 0.46 ng/dL which increased to 3.06 ng/dL after five hours. An initial diagnosis of NSTEMI was made, and the patient was started on a heparin infusion. Urgent coronary catheterization was organized.
Coronary angiogram demonstrated a nonobstructive coronary artery disease (Figures
Coronary angiogram showing LAD caudal view.
Coronary angiogram showing a view of the right coronary artery.
Left ventriculogram in systole.
Left ventriculogram in diastole.
Apical 4 chamber ECHO view (a) on presentation suggestive of takotsubo cardiomyopathy followed by repeat apical 4 chamber view (b) two months later showing recovery of previously noted wall motion abnormalities.
EKG showing Mobitz type 1 AV block.
EKG showing third degree complete AV block.
A repeat echocardiogram was done outpatient, two months after hospitalization, and showed improvement: she had an ejection fraction of 55-60% with resolution of the apical ballooning and hyperdynamic wall motion changes, which were initially noted during hospitalization (Figure
Takotsubo syndrome is deemed clinically benign with most characteristic features reversing with supportive therapy within months. The wall motion abnormalities characteristic of takotsubo cardiomyopathy usually reverse completely. High-degree AV blocks and complete heart block accompanying takotsubo cardiomyopathy are a rare phenomenon [
Despite increasing knowledge and awareness of the historically enigmatic takotsubo syndrome, it is still believed to be a relatively benign and self-resolving entity. The recognition of AV conduction defects along with conventional and more common features is important as they may not resolve along with other features and may need intervention such as pacemaker implantation. Such situations are under recognized but are potentially life threatening and need timely management for patient safety.
No conflict of interest has been identified with any of the authors.
This is a four-chamber apical view on a transthoracic echocardiogram of the patient during her index hospitalization which shows the hyperdynamic inferobasal and anterobasal walls with apical ballooning consistent with Takotsubo cardiomyopathy. It also shows her EF to be around 40% with normal biatrial size, normal valvular function, and no pericardial effusion.