takotsubo cardiomyopathy is characterized by transient left ventricular ( lv ) regional wall motion abnormalities and usually involves apical segments in the absence of significant coronary artery stenosis . in the recent years , several cases on atypical forms of transient lv ballooning syndrome have been reported . the pathophysiological mechanisms remain unclear , however , the catecholamine excess and increased sympathetic activity are likely to play a pivotal role in triggering this syndrome.1 - 3 ) in this report , we describe an unusual case of a 38-year - old woman who had pulmonary embolism ( pe ) and reverse takotsubo cardiomyopathy . pe has been listed as stressors of stress - induced cardiomyopathy,2)3 ) because the pain and the decreased perfusion within the lung related to pe probably cause a release of catecholamines.4)5 ) however , it is uncommon to present reverse types of stress - induced cardiomyopathy in the setting of pe for our patient . a 38-year - old woman with no history of cardiac diseases or cardiac risk factors was referred to our emergency department because of chest discomforts , arrhythmia and shortness of breath after the surgery . a few days before she had fallen off the ladder and underwent surgery for right lateral malleolar fracture under spinal anesthesia . physical examination revealed vital signs as follows : blood pressure 90/60 mm hg , heart rate 75 beats / min , body temperature 36.7 , respiratory rate 22/min and oxygen saturation 88% on room air . the electrocardiogram ( ecg ) recording showed sinus rhythm , st - segment depression in v3 through v5 , and there were no typical features of ecg abnormalities associated with pe such as sinus tachycardia , s1q3t3 pattern , complete and incomplete rbbb , and t wave inversion ( fig . chest radiography showed diffuse increased bronchovascular lung markings with mild congestion and edema , d - dimer was elevated to 1572 ng / ml ( normal reference range 0 - 243 ng / ml ) and altered results of the arterial blood gas analysis ( ph 7.42/pco2 25.8 mm hg / po2 69.7 mm hg / hco3 16.4 mmol / l ) aroused suspicion of pe . it was confirmed by computed tomography and thus , therapy with heparin infusion was initiated ( fig . other laboratory findings indicated white blood cell counts of 10000/mm ; hemoglobin 9.7 g / dl ; platelet count 275000/mm ; c - reactive protein 0.0 mg / dl ; alanine aminotransferase 18 u / l ; aspartate aminotransferase 39 u / l ; total bilirubin 0.46 mg / dl ; and serum creatinine 0.7 mg / dl . the cardiac enzyme levels were elevated with a peak level of creatine kinase - mb isoform 27 ng / ml ( normal reference range 0 - 3.6 ng / ml ) and troponin i 5.30 ng / ml ( normal reference range 0 - 0.1 ng / ml ) . transthoracic echocardiography showed hypokinesia of mid / base segments of lv with hypercontraction of apical segments and reduced ejection fractions estimated at 47% with no significant valvular dysfunctions . right ventricular systolic dysfunction or dilated right ventricle was not found , and yet an estimated systolic pulmonary artery pressure increased mildly to 43 mm hg on the assumption of right arterial pressure of 10 mm hg ( tricuspid regurgitation peak velocity : 2.87 m / s ) ( fig . coronary angiography was immediately performed within an hour of admission and ruled out obstructive atherosclerotic diseases . she was managed with medical therapy using -blocker and diuretics.2)3)6)7 ) angiotensin converting enzyme inhibitors was not indicated because of mild hypotensions . after the medical treatment , the patient was presented free of symptoms for the following few days . transthoracic echocardiography was undergone 1 week after her admission and showed improvements in ejection fractions of 58% with no wall motion abnormalities ( fig . the patient was discharged in good clinical conditions and remained well after 3 months of follow - up . takotsubo cardiomyopathy , also known as apical ballooning syndrome , is generally characterized as severe , reversible lv dysfunctions of apical segments . variants , the non - apical ballooning syndrome , have been recognized as reversed , mid - ventricular , and localized type based on the involvement of the left ventricular.8 ) our case is consistent with the reverse type , hyperdynamic apex and akinesia of the mid / base segments of lv . compared to typical lv ballooning syndrome , this atypical form of transient lv ballooning syndromes have different characteristics of patients.6)8 ) hahn et al.6 ) described that patients with atypical transient lv ballooning syndrome were younger with the mean age of 36 and had fewer coronary risk factors such as hypertensions , diabetes , and smoking habits . also , t wave inversion in an ecg was found as less similar to our patient . however , according to the recent reviews and many published clinical cases , the excessive catecholamine and exaggerated sympathetic activities are greatly accountable.1 - 3)9 - 11 ) differences in anatomical location and density of cardiac adrenergic receptors and the degree of sympathetic activity may explain the wall motion abnormalities as seen in the typical and reverse types.8)11)12 ) clinical presentations and transient nature of lv wall motion abnormalities in reverse type are similar to those of classic takotsubo cardiomyopathy which could indicate a possibility of sharing pathophysiological mechanisms , and yet , none of related evidences has been revealed . estrogens , which have a protective effect on cathecholamine - induced toxicity , appear to have influences on the preponderances of postmenopausal women toward takotsubo cardiomyopathy.1)2)13 ) however , further researches for the interaction of catecholamines and estrogen are necessary to clarify the underlying mechanisms of stress - induced cardiomyopathy at a younger age without estrogen deficiency , and the specific reasons for rare presentations of men with physiologically estrogen - deficient . takotsubo cardiomyopathy has been described with a wide range of emotional or physical stressful triggers . herein , we report a middle - aged woman with inverted takotsubo cardiomyopathy in the setting of pe , which is a rare coexistence for this association . the exact mechanisms of the relation between pe and atypical takotsubo cardiomyopathy are not clear . but increased catecholamine levels during severe pain and perfusion defect within the lung related to pe seem to result in the development of lv wall motion abnormalities.4)5 ) in this case , it is difficult to detect pe and reverse takotsubo cardiomyopathy independently , due to the fact that both clinical features mimic acute coronary syndromes . despite of the poor sensitivity and specificity of ecg abnormalities to diagnose pe and inverse takotsubo cardiomyopathy , there are several frequent features including sinus tachycardia , both complete and incomplete rbbb , s1q3t3 pattern , and st - segment elevation , non specific t wave abnormalities , respectively.2)4 - 6 ) a transthoracic echocardiography ( tte ) provide the evidence of pe such as right ventricular systolic dysfunctions and pulmonary hypertensions,4)5 ) and stress - induced cardiomyopathy may have right ventricular involvement which is associated with more severe impairments in lv systolic functions.14 ) thus , it is important to carry out ecg promptly , tte and coronary angiography based on a high degree of clinical suspicions . further research is needed to elucidate this relationship and different pathophysiological mechanisms for various ventricular morphologies of stress - induced cardiomyopathy . diagnosing pe especially in a patient with characteristics of acute coronary syndrome such as stressinduced cardiomyopathy can be difficult . it needs to be highlighted that pe should be considered as a potential stressor once the reverse takotsubo syndrome is suspected .
as the use of early coronary angiography and echocardiography become widely available in the setting of acute coronary syndrome , the gradual increase for variant forms of transient left ventricular ( lv ) apical ballooning syndrome have been recognized . 
 this syndrome usually occurs in women and is frequently elicited by an intense emotional , psychological , and physical event . while the patients ' characteristics between typical and non - typical lv ballooning syndrome seem to differ , the presentation , clinical features , and reversibility of lv wall motion abnormalities are similar . 
 we present a middle - aged woman who experienced inverted takotsubo cardiomyopathy triggered by pulmonary embolism . to the best of our knowledge 
 , this case is particularly unique and is rarely reported in the disease entity .