Takotsubo syndrome and complete heart block, which came first? A case report

Background In 2018 the European society of cardiology published two consensus documents on takotsubo syndrome which include the current consensus on nomenclature, diagnosis, management and complications. However, little is mentioned on the association with complete heart block, except that “AV block [occurs in] 2.9% of cases”. Complete heart block is a recognised rare association of takotsubo syndrome, but causation is often unclear. Does complete heart block trigger takotsubo syndrome or vice-versa? Here we present a case of takotsubo syndrome associated with complete heart block. Case summary An 89-year-old woman presented with a transient loss of consciousness, acute chest pain and dyspnoea. A few days prior to this her daughter died suddenly of a myocardial infarction. On presentation troponin levels were elevated, the ECG showed complete heart block with a broad QRS and an echo showed apical akinesis and ballooning. Angiographic investigation excluded significant coronary artery disease. A dual chamber pacemaker was implanted after a brief period of temporary pacing. Ventricular function normalized during Follow-up and her underlying rhythm remained complete heart block. Discussion Takotsubo syndrome may be triggered by both emotional and physical stressors. Complete heart block is recognised association but causation is often unclear. In our case a clear emotional trigger was identified suggesting the takotsubo syndrome may have precipitated complete heart block not vice versa.