When Fasting Breaks the Heart: Mid-Cavity Variant of Takotsubo Cardiomyopathy

Description of Clinical Presentation: A 61-year-old woman, with no prior history of hypertension or diabetes, presented with acute chest pain after five months of rigorous religious fasting consisting of alternate-day water-only intake. Laboratory evaluation revealed mildly elevated high-sensitivity troponin I (0.17 ng/mL) and NT-proBNP (297 pg/mL). ECG demonstrated T-wave inversion in leads I, aVL, V1–V3, and ST-segment depression in the inferior-lateral leads, findings initially suggestive of acute coronary syndrome.

Diagnostic Techniques and Their Most Important Findings: Coronary angiography performed to evaluate for obstructive coronary artery disease revealed normal coronary arteries. Two-dimensional echocardiography showed severely reduced left ventricular systolic function (LVEF 27%) with markedly reduced global longitudinal strain (–4.4%). To further characterize the underlying cardiomyopathy, cardiac MRI was performed. Cine MRI confirmed moderate systolic dysfunction (LVEF 30%) with a striking regional wall motion abnormality involving all mid-cavity segments, while apical and basal segments were preserved and normokinetic. Tissue characterization demonstrated elevated T2 values at the mid-ventricular segments, consistent with myocardial edema, while native T1 mapping was within normal limits. Importantly, there was no late gadolinium enhancement, excluding infarction or myocarditis. These findings established the diagnosis of mid-cavity variant Takotsubo cardiomyopathy.

The patient was managed conservatively with standard heart failure therapy and supportive care. On follow-up, repeat echocardiography showed complete functional recovery, confirming the transient and reversible nature of the condition.

Learning Points from this Case: This case highlights a rare mid-cavity variant of Takotsubo cardiomyopathy, precipitated by prolonged metabolic and physical stress associated with severe fasting. It underscores the importance of a multimodality imaging approach—while ECG and biomarkers suggested acute coronary syndrome, the absence of obstructive CAD on angiography, combined with characteristic cardiac MRI findings of regional mid-ventricular dysfunction, myocardial edema without necrosis, and absence of LGE, were crucial in establishing the correct diagnosis. Awareness of such variants is essential to avoid misdiagnosis, unnecessary interventions, and to ensure appropriate supportive management. This case also emphasizes the excellent prognosis of stress cardiomyopathy, with full recovery of ventricular function on follow-up.

Static images from long axis cine SSFP in diastole (Upper row, white box) and systole (lower row, blue box). It shows akinesia of mid segments resulting in an apparent mid cavity balooning. The basal and apical segments show normal contractility.
T2 mapping shows elevated T2 values 52 ms in mid cavity segments (black arrow)
Magnitude delayed enhancement images showing no LGE.