Takotsubo cardiomyopathy in patients with borderline stenosis of the left anterior descending artery and vasospastic angina: to stent or not to stent? A case report.

Background: Takotsubo cardiomyopathy (TCM) is a complex disease that resembles the clinical presentation of acute myocardial infarction with non-obstructive coronary arteries. The aetiology remains elusive despite the comprehensive nature of current guidelines meticulously detailing the diagnostic process.

Case summary: We present the case of a 64-year-old female who presented with a clinical profile consistent with non-ST elevation myocardial infarction, confirmed by elevated cardiac enzyme levels. Echocardiography raised suspicions of TCM. Angiography presented a challenge, revealing a 65% stenosis of the left anterior descending artery (LAD). Based on the collected evidence, we decided to delay and ultimately forgo LAD revascularization while identifying epicardial vasospasm through a provocation test as a possible cause underlying TCM.

Discussion: Conducting an acetylcholine provocation test, as recommended by the European Society of Cardiology guidelines for patients with ischaemia and no obstructive coronary artery disease unveiled severe diffuse vasospasm affecting both the LAD and circumflex arteries. The intricate interplay of pathophysiological mechanisms and clinical presentations necessitates ongoing exploration to uncover the mysteries and refine our diagnostic and therapeutic strategies.