broken heart syndrome is now increasingly recognised non - ischaemic cardiomyopathy seen as 2% of acute coronary syndrome ( acs ) presentations with a predilection for women older than 50 years of age . tcm is characterised by transient left ventricular ( lv ) dysfunction and electrocardiographic ( ecg ) changes that mimic acute myocardial infarction ( mi ) with minimal release of myocardial enzymes in the absence of obstructive coronary artery disease . this syndrome was first described in japan by sato et al . and dote et al . and named  takotsubo - shaped cardiomyopathy due to unique  short neck - round flask like lv apical ballooning resembling the takotsubo ( octopus trap or pot ) . we present the case of a 65-year - old female patient presenting with tcm precipitated by negative pressure pulmonary oedema following total thyroidectomy . a 65-year - old female patient who had undergone total thyroidectomy under general anaesthesia at a general hospital was brought intubated to our coronary care unit with ecg changes of st segment elevation in v2v4 leads . a brief history of the perioperative events revealed that the patient was an elderly female belonging to the american society of anesthesiologists physical status class 1 , non - diabetic , non - hypertensive , euthyroid with multinodular goitre for the past 2 years and was posted for total thyroidectomy . her pre - operative egg and blood reports , including thyroid profile , were normal . total thyroidectomy was performed under general anaesthesia , and the intra - operative course was uneventful . soon after extubation , the patient developed stridor and the pulse oximetry showed drop in oxygen saturation ( spo2 ) to 75% . she was administered 100% oxygen with mask , but could not maintain spo2 above 85% and was re - intubated . the patient was ventilated with positive end - expiratory pressure ( peep ) of 10 cm of water and spo2 increased to 95% . she had transient hypotension for which mephentermine 6 mg was administered intravenously ( iv ) and dopamine was started at 5 g / kg / min . ecg changes were noted half - an - hour later in the anterior leads v2v4 and the patient was shifted to cardiac centre . the patient was sedated and intubated on arrival at our cardiac centre . blood pressure was 100/70 mm hg and spo2 was 97% with inspired oxygen concentration of 70% . cardiac enzymes were mildly elevated with troponin - t at 0.261 ng / ml ( normal range 0.0100.100 ng / ml ) and creatinine kinase - mb isoenzyme at 49 u / l ( normal up to 24 u / l ) . two - dimensional echocardiogram showed lv ejection fraction of 40% with lv segmental hypokinesia involving apex , apical anterior , apical inferior , mid - septal and distal inter - ventricular septum . a provisional diagnosis of anterior wall mi was made , and the patient was taken up for coronary intervention . the coronary angiogram revealed normal coronaries [ figure 2a ] . a diagnosis of tcm ( stress cardiomyopathy ) was made and supportive treatment was given with continued mechanical ventilation with peep of 10 cm of water and inj.furosemide for lv dysfunction . the patient was extubated after 24 h of ventilation , after obtaining satisfactory chest x - ray and weaning criteria . mild tracheomalacia was suspected ( although the size of the goitre was small ) in view of its long - standing nature along with unilateral vocal cord palsy . the patient was re - intubated with 7.0 mm cuffed endotracheal tube after induction of anaesthesia with midazolam 2 mg , fentanyl 200 g , propofol 20 mg and succinylcholine 50 mg iv . , the patient was haemodynamically stable with normal ecg [ figure 2b ] and persistent regional wall motion abnormalities on echocardiogram . she was advised to come back after 6 weeks for a follow - up echocardiogram . it is most common in post - menopausal women . in a systematic review , women accounted for 82100% of patients with an average age of 6275 years . the presentation of tcm is similar to that of an acs with symptoms of ischaemia - like chest pain and ischaemia - like ecg changes in most patients . as a result , the american and international guidelines have now included tcm as an important differential diagnosis of acs . collective reports have shown that severe emotional stress had preceded presentation with tcm in 27% of reported cases . reported emotional precipitants include death of a family member , fierce arguments , financial loss , automobile accidents and natural disasters such as earthquakes . approximately 38% of tcm cases occur in the setting of an acute medical illness or surgery , but , importantly , in some patients , no precipitating event can be identified . the modified mayo clinic criteria for the diagnosis of tcm can be applied to a patient at the time of presentation and must include all 4 aspects as follows : 
 transient hypokinesis , dyskinesis or akinesis of the lv mid - segments , with or without apical involvement ; the regional wall - motion abnormalities extending beyond a single epicardial vascular distribution , and a stressful trigger is often , but not always , presentabsence of obstructive coronary disease or angiographic evidence of acute plaque rupturenew ecg abnormalities ( either st - segment elevation and/or t - wave inversion ) or modest elevation in cardiac troponin levelabsence of phaeochromocytoma or myocarditis . transient hypokinesis , dyskinesis or akinesis of the lv mid - segments , with or without apical involvement ; the regional wall - motion abnormalities extending beyond a single epicardial vascular distribution , and a stressful trigger is often , but not always , present absence of obstructive coronary disease or angiographic evidence of acute plaque rupture new ecg abnormalities ( either st - segment elevation and/or t - wave inversion ) or modest elevation in cardiac troponin level absence of phaeochromocytoma or myocarditis . the physical stressor that led to tcm was the surgery itself as well as the post - operative negative pressure pulmonary oedema , probably caused by laryngospasm , unilateral vocal cord palsy , mild tracheomalacia and possibly , residual neuromuscular blockade . tcm in the form of non - st elevation mi following shoulder surgery is reported . our case presented as st - elevation mi in which immediate cardiac catheterisation has important implications in the management . multiple aetiologies for tcm have been hypothesised including catecholamine excess , neurogenic stunning due to emotional or physical stress , microvascular dysfunction , multivessel coronary spasm and wrap around left anterior descending artery . treatment and initial clinical management of patients with tcm is similar to that of patients with acs . sympathetic activation is believed to contribute to the pathogenesis of tcm , and thus , it is reasonable to consider long - term -blocker therapy with the goal of preventing recurrence . the use of angiotensin - converting enzyme inhibitors or angiotensin receptor blockers should be considered until lv function has normalised . hypotension in some patients may result because of lv outflow tract obstruction in which inotropic agents are contraindicated , and hypotension can be treated with judicious use of fluids and short - acting -blockers . inotropes are also contraindicated in patients with hypotension because of pump failure , who are best treated with intra - aortic balloon pump support . a short duration of anticoagulation with warfarin may be considered for patients with persistent , significant reduction in lv function to prevent lv thrombus formation and embolisation . follow - up echocardiography before hospital discharge to reassess lv systolic function is advised . follow - up echocardiogram at 1 and 3 months in those with persistent lv dysfunction is required . the prognosis in tcm is excellent , with nearly 95% of patients experiencing complete recovery within 48 weeks . the annual recurrence rate is approximately 1.5% ; estimates of mortality rates have ranged from 1% to 3.2% . patients who suffer from tcm as a result of physical stress have an increased risk of mortality . management of critically ill patients with tcm may be challenging because the use of exogenous catecholamines for circulatory support might worsen cardiomyopathy . complications occur in 20% of tcm cases and include left heart failure , cardiogenic shock , lv outflow obstruction , mitral regurgitation , ventricular arrhythmias , lv mural thrombus formation , lv free wall rupture and death . tcm should be considered in the differential diagnosis of patients presenting with acs , especially when there is a strong emotional or physical stressor . a high index of suspicion is required because early recognition and cardiac catheterisation establishes diagnosis and can prevent unnecessary drug therapy and its sequelae .
takotsubo cardiomyopathy ( tcm) or 
 stress cardiomyopathy is a reversible cardiomyopathy that is precipitated by intense emotional or physical stress . 
 this syndrome is characterised by symptoms mimicking acute coronary syndrome with transient systolic dysfunction associated with regional wall motion abnormalities , which extend beyond a single coronary vascular bed in the absence of obstructive coronary vascular disease . 
 the presentation of tcm and myocardial infarction is similar with sudden onset of chest pain , breathlessness as well as abnormalities in both the electrocardiogram and cardiac enzymes . 
 it is difficult to differentiate between the two until cardiac catheterisation establishes the diagnosis . 
 we report a case of tcm in a post - menopausal female , precipitated by negative pressure pulmonary oedema following total thyroidectomy in whom timely cardiac catheterisation established the diagnosis and influenced the management . 
 heightened awareness of this unique cardiomyopathy is essential to have a high index of suspicion in at - risk population for the prompt diagnosis of stress - related cardiomyopathy syndromes occurring in the perioperative period .