Massive pulmonary embolism triggering Takotsubo syndrome initially misdiagnosed as STEMI after knee surgery: a case report and diagnostic pitfall

Massive pulmonary embolism triggering Takotsubo syndrome initially misdiagnosed as STEMI after knee surgery: a case report and diagnostic pitfall | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Massive pulmonary embolism triggering Takotsubo syndrome initially misdiagnosed as STEMI after knee surgery: a case report and diagnostic pitfall Tiezhu Yao, Xiangtong Diao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8443263/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Takotsubo syndrome (TTS) can mimic ST-elevation myocardial infarction (STEMI) on presentation. Pulmonary embolism (PE) is a recognized physical trigger for TTS but the co-occurrence remains uncommon and diagnostically challenging, especially when ST-segment elevation and severe hypoxemia coexist. Case presentation: A 70-year-old woman presented with acute dyspnea and syncope 10 days after arthroscopic meniscal surgery. Initial electrocardiogram (ECG) in a local hospital showed extensive ST-segment elevation (V1–V6, V3R–V5R); she received alteplase for presumed anterior STEMI. Transferred to our intensive care unit (ICU) in shock with hypoxemia, bedside echocardiography showed left ventricular ejection fraction (LVEF) of 40% and low velocity-time integral (VTI) of 12 cm. Emergency coronary angiography (CAG) revealed no obstructive lesions; left ventriculography demonstrated apical akinesia with ballooning, supporting TTS. Given persistent hypoxemia and right-heart strain, CT pulmonary angiography (CTPA) confirmed massive PE. Systemic alteplase was administered per high-risk PE recommendations, alongside intra-aortic balloon pump (IABP) support and heparin. Coagulation was closely titrated (activated partial thromboplastin time [APTT] peaked 93.6 s, fibrinogen nadir 1.45 g/L; corrected with cryoprecipitate). Serial echo documented recovery of LVEF to 50% and rising VTI (to 27.3 cm) with persistent but improving right-heart parameters. She was transitioned to warfarin with low-molecular-weight heparin (LMWH) bridging; international normalized ratio (INR) stabilized around 2.0–2.1 and she was discharged in stable condition. Conclusions In elderly postoperative patients with ST-elevation plus hypoxemia and markedly elevated D-dimer, clinicians should maintain high suspicion for PE-triggered TTS. Rapid integration of CAG/ventriculography, CTPA, serial echocardiography, and dynamic biomarkers can prevent misdiagnosis and optimize therapy (systemic thrombolysis for high-risk PE, tailored hemodynamic support for TTS). This case highlights a diagnostic pitfall and the value of multidisciplinary management. Takotsubo syndrome pulmonary embolism ST-segment elevation thrombolysis intra-aortic balloon pump postoperative deep vein thrombosis Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8443263","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":575050897,"identity":"23d3e91b-e844-4531-bc27-aac1f3ebdf96","order_by":0,"name":"Tiezhu 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pitfall","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Takotsubo syndrome, pulmonary embolism, ST-segment elevation, thrombolysis, intra-aortic balloon pump, postoperative deep vein thrombosis","lastPublishedDoi":"10.21203/rs.3.rs-8443263/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8443263/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTakotsubo syndrome (TTS) can mimic ST-elevation myocardial infarction (STEMI) on presentation. Pulmonary embolism (PE) is a recognized physical trigger for TTS but the co-occurrence remains uncommon and diagnostically challenging, especially when ST-segment elevation and severe hypoxemia coexist.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 70-year-old woman presented with acute dyspnea and syncope 10 days after arthroscopic meniscal surgery. Initial electrocardiogram (ECG) in a local hospital showed extensive ST-segment elevation (V1\u0026ndash;V6, V3R\u0026ndash;V5R); she received alteplase for presumed anterior STEMI. Transferred to our intensive care unit (ICU) in shock with hypoxemia, bedside echocardiography showed left ventricular ejection fraction (LVEF) of 40% and low velocity-time integral (VTI) of 12 cm. Emergency coronary angiography (CAG) revealed no obstructive lesions; left ventriculography demonstrated apical akinesia with ballooning, supporting TTS. Given persistent hypoxemia and right-heart strain, CT pulmonary angiography (CTPA) confirmed massive PE. Systemic alteplase was administered per high-risk PE recommendations, alongside intra-aortic balloon pump (IABP) support and heparin. Coagulation was closely titrated (activated partial thromboplastin time [APTT] peaked 93.6 s, fibrinogen nadir 1.45 g/L; corrected with cryoprecipitate). Serial echo documented recovery of LVEF to 50% and rising VTI (to 27.3 cm) with persistent but improving right-heart parameters. She was transitioned to warfarin with low-molecular-weight heparin (LMWH) bridging; international normalized ratio (INR) stabilized around 2.0\u0026ndash;2.1 and she was discharged in stable condition.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn elderly postoperative patients with ST-elevation plus hypoxemia and markedly elevated D-dimer, clinicians should maintain high suspicion for PE-triggered TTS. Rapid integration of CAG/ventriculography, CTPA, serial echocardiography, and dynamic biomarkers can prevent misdiagnosis and optimize therapy (systemic thrombolysis for high-risk PE, tailored hemodynamic support for TTS). This case highlights a diagnostic pitfall and the value of multidisciplinary management.\u003c/p\u003e","manuscriptTitle":"Massive pulmonary embolism triggering Takotsubo syndrome initially misdiagnosed as STEMI after knee surgery: a case report and diagnostic pitfall","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-26 01:20:19","doi":"10.21203/rs.3.rs-8443263/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a839ccba-33b6-4596-8d8b-1ea934db904c","owner":[],"postedDate":"January 26th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T08:26:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-26 01:20:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8443263","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8443263","identity":"rs-8443263","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}