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

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

The Ominous Triad of Severe Takotsubo Cardiomyopathy


Figure 1.
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.
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.
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 testPatient’s resultReference range
White cells count (WCC)10 × 103/µL3.3 - 10.7 × 103/µL
Hemoglobin12.2 g/dL12.1 - 15.0 g/dL
Mean corpuscular volume (MCV)95 fL80 - 100 fL
Platelets286 × 103/µL150 - 400 × 103/µL
Serum sodium138 mmol/L133 - 144 mmol/L
Serum chloride99 mmol/L98 - 107 mmol/L
Serum potassium3.9 mmol/L3.5 - 5.2 mmol/L
Serum bicarbonate20 mmol/L21.0 - 28.0 mmol/L
Anion gap13 mEq/L3 - 11 mEq/L
Serum calcium8.9 mg/dL8.6 - 10.8 mg/dL
Serum magnesium1.3 mg/dL1.6 - 3.0 mg/dL
Blood urea nitrogen (BUN)31 mg/dL9.0 - 25.0 mg/dL
Serum creatinine1.34 mmol/L0.5 - 1.2 mmol/L
Serum glucose158 g/dL70 - 140 g/dL
Aspartate aminotransferase (AST)87 U/L7 - 52 U/L
Alanine aminotransferase (ALT)51 U/L13 - 39 U/L
International normalized ratio (INR)1.07< 1.1
Lactic acid3.7 mmol/L0.5 - 2.2 mmol/L
High-sensitivity troponin I17 ng/mL0 - 0.4 ng/L
Brain natriuretic peptide (BNP)249 pg/mL< 450 pg/mL
Thyroid-stimulating hormone (TSH)3.95 µIU/mL0.5 - 5 µIU/mL


Table 2. QTc and Heart Rate (HR) Trends in Real-Time From the Time of Admission
Hospital stayaTimeHR (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 116:2847509
Day 216:2085466


Table 3. Similar Case of Takotsubo Cardiomyopathy With High Degree AV Block, QT Prolongation, and TdP Resulting in Near Arrest (NA) or Cardiac Arrest (CA) Within 24 - 48 h of Hospital Admission
ArticleAge/sexPast medical historyECG rhythm on admissionDuration of QT interval on admission ECGTTE findingsTiming of NA or CARhythm causing NA or CATemporality of TTE findings with TdP and/or CATiming of PPP
ECG: electrocardiogram; VF: ventricular fibrillation; CV: cardioversion; EJR: escape junctional rhythm; HB: heart block; RBBB: right bundle branch block; AVB: atrioventricular block; TWI: T wave inversion; VR: ventricular rate; PVC: premature ventricular contractions; TdP: torsade de pointes; TTE: transthoracic echocardiogram; b/min: beats/min; HTN: hypertension; TVP: temporary venous pacing; PPP: permeant pacemaker placement; LAFB: left anterior fascicular block; LVEF: left ventricular ejection fraction.
Ahn et al, 2011 [27]78/FHTNThird-degree HB with EJR of 35 b/min, combined with TWI precordial leads580 msAkinesia of mid and apical LV walls with the systolic ballooning of the ventricular apex; LVEF: 35%24 - 48 hThird-degree HB with EJR of 20 b/min QTc 720 ms followed by TdP (treated by CV and TVP)BeforeDay 21
de Santana et al, 2021 [24]56/FHTN, grade 2 obesitySecond degree AVB 2:1 with EJR of 50 b/min, RBBB, LAFB, biphasic and inverted T waves in precordial and limb leads689 msBasal hypercontractility and midventricular and apical ballooning. LVEF: 40%24 hVF (treated by CV and TVP)BeforeDay 14
Inayat et al, 2017 [8]59/FNoneThird-degree AVB with EJ VR 48 b/min, multiple PVCs, prolonged, and deep TWI in limb leads643 msBasal hyperkinesia and apical hypokinesis with LVEF of 35-40%24 - 48 hTdP (treated medically and TVP)BeforeDay 6
Kurisu et al, 2008 [26]87/FSyncopeRBBB during 2:1 AVB with a VR of 42 b/min, TWI in leads I, II, aVL, aVF and V1 to V6880 msAkinesia of the distal portion of the LV chamber, LVEF 62%ImmediatelyTdP (treated medically and TVP)AfterDay 10
Kurisu et al, 2008 [26]78/FNot reportedRBBB during complete AVB with a VR of 40 b/min, ST segment elevation in leads V2 to V6, T wave inversion in leads I, II, III, aVF and V1 to V6920 msAkinesia of the mid to distal portion of the LV chamber, LVEF 38%ImmediatelyTdP (treated medically and TVP)AfterDay 7