When Grief Strains the Heart: A Case of Reverse Takotsubo Cardiomyopathy Triggered by Mourning and Respiratory Failure

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BACKGROUND Takotsubo cardiomyopathy is a transient stress-induced cardiomyopathy that can mimic acute coronary syndrome (ACS) but typically occurs without obstructive coronary disease. Reverse takotsubo is an uncommon variant characterized by basal hypokinesis with preserved apical contraction. We report an atypical case in which acute respiratory failure, rather than an abrupt emotional stressor, appeared to be the primary trigger. CASE REPORT A 69-year-old woman with coronary artery disease status after prior left anterior descending artery stent, hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD) presented with severe respiratory distress and became unresponsive, requiring emergency intubation. She tested positive for coronavirus OC43 and was managed in the intensive care unit (ICU) for COPD exacerbation with ventilator-dependent respiratory failure. High-sensitivity troponin rose from 56 ng/L to 937 ng/L initially, later peaking at 1928 ng/L after catheterization with ST-T changes on EKG, prompting cardiac evaluation. Transthoracic echocardiography revealed new segmental wall motion abnormalities consistent with stress cardiomyopathy and an estimated ejection fraction of 40%. Urgent coronary angiography demonstrated no obstructive coronary disease with a patent LAD stent; left ventriculography showed severe basal hypokinesis with preserved apical contraction, confirming reverse takotsubo. Further history-taking revealed ongoing grief after her sister's death 3 months earlier. CONCLUSIONS Reverse takotsubo should be considered in patients with ACS-like presentations during acute critical illness, including respiratory failure, even when emotional stressors are chronic rather than sudden. Recognizing basal hypokinesis with preserved apical function can help avoid misdiagnosis and guide appropriate supportive management and follow-up imaging.

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