# Takotsubo Cardiomyopathy Complicated by High-Grade Atrioventricular Block in a Patient With Preexisting Conduction Disease: A Case Report

## TL;DR

A 79-year-old woman with preexisting heart conditions developed a rare complication of takotsubo cardiomyopathy, requiring a specialized pacemaker.

## Contribution

This case report highlights the rare occurrence of high-grade AV block in takotsubo cardiomyopathy with preexisting conduction disease.

## Key findings

- Takotsubo cardiomyopathy was confirmed with apical ballooning and unobstructed coronaries.
- The patient developed Mobitz II AV block progressing to high-grade AV block.
- A CRT-P pacemaker was implanted due to poor systolic function and high pacing dependency risk.

## Abstract

Takotsubo cardiomyopathy (TTC) often mimics acute coronary syndrome, presenting with chest pain, electrocardiogram (ECG) changes, and troponin rise. While usually reversible, it can rarely be complicated by conduction abnormalities such as high-grade atrioventricular (AV) block.

We report a 79-year-old woman with poorly controlled hypertension and preexisting trifascicular block who presented with chest pain precipitated by extreme emotional stress due to the inability to obtain her antihypertensive tablets prescription via her General Practitioner, coinciding with the anniversary of her husband’s death. Initial evaluation based on her 12-lead ECG was in keeping with a lateral ST elevation myocardial infarction, but emergency invasive coronary angiography revealed unobstructed coronaries with classical apical ballooning of the left ventricle. Transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (MRI) within 48 hours confirmed TTC. Over the following days, she developed Mobitz II AV block progressing to high-grade AV block. Given her persistent poor left ventricular systolic function and high risk of pacing dependency, the consensus opinion after discussion in the multidisciplinary device team meeting opted for a cardiac resynchronisation therapy pacemaker (CRT-P), which was implanted successfully.

This case highlights the rare association between TTC and high-grade AV block, particularly in patients with underlying conduction disease. Early recognition and individualised pacing strategies are essential for improving outcomes.