‘Is the Patient Clear for Surgery?’ Takotsubo Cardiomyopathy Presenting as T-Wave Inversions in a Pre-Operative EKG: A Case Report

Takotsubo cardiomyopathy (TC) can cause dynamic changes in the electrocardiogram (EKG) and troponin elevation which can be misinterpreted as an acute coronary event that can cause an unnecessary delay in the surgery and affect the outcomes of a non-cardiac surgery. We present a case of a patient with pre-operative T-wave inversions diagnosed with TC. A 90-year-old female presented with a femur fracture. Pre-operative EKG showed symmetric T-wave inversions in the inferior and pre-cordial leads. Delta troponin was unremarkable and she remained chest pain-free. Transthoracic echocardiogram (TTE) showed an ejection fraction of 60% with apical ballooning and basal hyperkinesis concerning for TC. The findings of TTE combined with unremarkable delta troponin and no chest pain pointed towards TC as opposed to a true coronary plaque rupture event. Given the urgency of the surgery, it was decided to defer a coronary angiogram as it would not change the management and would cause an unnecessary delay in the surgery. Repeat EKG showed partial resolution of T-wave inversions with no progressive dynamic ischemic changes and she successfully underwent surgery without any delay. TC can manifest with acute dynamic EKG changes resembling an acute coronary event. It is essential to differentiate between the two entities to avoid unnecessary surgery delays and prevent exposure to invasive cardiac testing pre-operatively. Early TTE is an important clinical tool to differentiate TTE from acute coronary syndrome (ACS) and guide medical decision-making.