J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website https://www.journalmc.org

Case Report

Volume 13, Number 7, July 2022, pages 341-348

The Ominous Triad of Severe Takotsubo Cardiomyopathy

Figure 1. ECG on admission demonstrated a junctional escape rhythm with right bundle branch block, 47 beats/min ventricular rate, and QTc of 509 ms. ECG: electrocardiogram.

Figure 2. ECG obtained immediately after ventricular fibrillation arrest showing complete heart block with an accelerated junctional rhythm with a heart rate of 67 beats/min and QTc of 407 ms. ECG: electrocardiogram.

Figure 3. Echocardiogram with (right image) and without (left image) contrast enhancement showing typical apical ballooning (blue arrow) with relatively spared basal segment and mid to apical segment akinesis.

**Table 1.** Laboratory Results on Presentation and Their Reference Ranges
Laboratory test	Patient’s result	Reference range
White cells count (WCC)	10 × 10³/µL	3.3 - 10.7 × 10³/µL
Hemoglobin	12.2 g/dL	12.1 - 15.0 g/dL
Mean corpuscular volume (MCV)	95 fL	80 - 100 fL
Platelets	286 × 10³/µL	150 - 400 × 10³/µL
Serum sodium	138 mmol/L	133 - 144 mmol/L
Serum chloride	99 mmol/L	98 - 107 mmol/L
Serum potassium	3.9 mmol/L	3.5 - 5.2 mmol/L
Serum bicarbonate	20 mmol/L	21.0 - 28.0 mmol/L
Anion gap	13 mEq/L	3 - 11 mEq/L
Serum calcium	8.9 mg/dL	8.6 - 10.8 mg/dL
Serum magnesium	1.3 mg/dL	1.6 - 3.0 mg/dL
Blood urea nitrogen (BUN)	31 mg/dL	9.0 - 25.0 mg/dL
Serum creatinine	1.34 mmol/L	0.5 - 1.2 mmol/L
Serum glucose	158 g/dL	70 - 140 g/dL
Aspartate aminotransferase (AST)	87 U/L	7 - 52 U/L
Alanine aminotransferase (ALT)	51 U/L	13 - 39 U/L
International normalized ratio (INR)	1.07	< 1.1
Lactic acid	3.7 mmol/L	0.5 - 2.2 mmol/L
High-sensitivity troponin I	17 ng/mL	0 - 0.4 ng/L
Brain natriuretic peptide (BNP)	249 pg/mL	< 450 pg/mL
Thyroid-stimulating hormone (TSH)	3.95 µIU/mL	0.5 - 5 µIU/mL

Table 1. Laboratory Results on Presentation and Their Reference Ranges

Laboratory test

Patient’s result

Reference range

White cells count (WCC)

10 × 10³/µL

3.3 - 10.7 × 10³/µL

Hemoglobin

12.2 g/dL

12.1 - 15.0 g/dL

Mean corpuscular volume (MCV)

95 fL

80 - 100 fL

Platelets

286 × 10³/µL

150 - 400 × 10³/µL

Serum sodium

138 mmol/L

133 - 144 mmol/L

Serum chloride

99 mmol/L

98 - 107 mmol/L

Serum potassium

3.9 mmol/L

3.5 - 5.2 mmol/L

Serum bicarbonate

20 mmol/L

21.0 - 28.0 mmol/L

Anion gap

13 mEq/L

3 - 11 mEq/L

Serum calcium

8.9 mg/dL

8.6 - 10.8 mg/dL

Serum magnesium

1.3 mg/dL

1.6 - 3.0 mg/dL

Blood urea nitrogen (BUN)

31 mg/dL

9.0 - 25.0 mg/dL

Serum creatinine

1.34 mmol/L

0.5 - 1.2 mmol/L

Serum glucose

158 g/dL

70 - 140 g/dL

Aspartate aminotransferase (AST)

87 U/L

7 - 52 U/L

Alanine aminotransferase (ALT)

51 U/L

13 - 39 U/L

International normalized ratio (INR)

1.07

< 1.1

Lactic acid

3.7 mmol/L

0.5 - 2.2 mmol/L

High-sensitivity troponin I

17 ng/mL

0 - 0.4 ng/L

Brain natriuretic peptide (BNP)

249 pg/mL

< 450 pg/mL

Thyroid-stimulating hormone (TSH)

3.95 µIU/mL

0.5 - 5 µIU/mL

**Table 2.** QTc and Heart Rate (HR) Trends in Real-Time From the Time of Admission
Hospital stay^a	Time	HR (beats/min)	QTc (ms)
^aPatient was admitted at 16:25. Notice the resolution of QTc interval prolongation following temporary venous pacing (TVP) with a programed lower rate limit (LRL) of 70 beats/min. QTC: corrected QT interval.
Day 1	16:28	47	509
	16:31	46	519
	17:00	41	537
	17:49	41	545
	17:50	41	536
	18:05	67	407
Day 2	16:20	85	466
	16:21	67	405
	22:00

Table 2. QTc and Heart Rate (HR) Trends in Real-Time From the Time of Admission

Hospital stay^a

Time

HR (beats/min)

QTc (ms)

^aPatient was admitted at 16:25. Notice the resolution of QTc interval prolongation following temporary venous pacing (TVP) with a programed lower rate limit (LRL) of 70 beats/min. QTC: corrected QT interval.

Day 1