a 44-year - old woman presented to the emergency room with shortness of breath and thoracic pain radiating to the left arm and shoulder .
her vital signs showed a blood pressure of 158/102  mmhg , a pulse rate of 135 beats / min , a normal temperature and oxygen saturation of 100% on room air and no signs of heart failure . laboratory research revealed an elevated troponin t of 0.18  g
/ l , a creatinine kinase of 170  u / l and ck - mb of 17.9 
non - significant coronary abnormalities were found by coronary angiogram . left ventriculogram showed akinetic wall motion abnormality in posterolateral and diaphragmatic wall segments , and a hypokinetic apex ( fig .  1 ) .
medical treatment with furosemide , anticoagulants and an ace inhibitor was started . on the ecg ,
negative t waves evolved combined with prolonged qt duration ( fig .  2 ) . 

1left ventriculogram with wall motion abnormalities in the distal segments and normal wall motion in basal segments comparative to stress - induced cardiomyopathy . a systolic phase , b diastolic phasefig . 
2ecg at admission ( a ) with slight st elevation in v2 and 16  h after admission ( b ) with negative t waves in the right precordial leads ,
i and avl with prolonged qt duration left ventriculogram with wall motion abnormalities in the distal segments and normal wall motion in basal segments comparative to stress - induced cardiomyopathy . a systolic phase , b diastolic phase ecg at admission ( a ) with slight st elevation in v2 and 16  h after admission ( b ) with negative t waves in the right precordial leads , i and avl with prolonged qt duration the patient appeared to have had a previous incidence of thyrotoxicosis ( graves disease ) in 2002 .
her current thyroid function confirmed a toxic state with a thyroid - stimulating hormone ( tsh ) of < 0.05  mu / l and free thyroxin ( t4 ) of > 100 
pmol / l and tri - iodothyronine ( t3 ) of 26  pmol / l .
six days after treatment with propylthiouracil and propanolol , her heart rate reduced to 80 beats / min and the sequential echocardiogram showed an improvement of her systolic left ventricular function ( fig .  3 ) . magnetic resonance imaging measured a left ventricular ejection fraction of 52% .
3transthoracic echocardiogram with return of normal systolic function after initiating medical treatment transthoracic echocardiogram with return of normal systolic function after initiating medical treatment
hyperthyroid patients can present with angina symptoms and abnormal ecgs in the absence of coronary artery disease .
a myocardial infarction can be induced due to increased demand . a hypertrophic heart due to an increase in cardiac protein synthesis is also seen .
forfar et al .   discovered that hyperthyroid patients have an elevated ejection fraction at rest but experience significant declines during exercise , also known as hyperthyroid cardiomyopathy .
we speculate that a surge of catecholamine release during physical stress in combination with a reduced ejection fraction caused by the thyrotoxicosis state resulted in severe left ventricular dysfunction .
after initialising medical treatment the symptoms were reduced and the left ventricular function returned to normal with borderline left ventricular hypertrophy remaining . in this case report
we demonstrate a combination of reversible cardiomyopathy related to stress ( tako tsubo ) and thyrotoxicosis that resolved completely with medical treatment .
 we report on a 44-year - old woman presenting with chest pain and dyspnoea without previous stress - related events . by means of echocardiography 
 severe left ventricular dysfunction and wall motion abnormalities resembling stress - induced cardiomyopathy ( tako tsubo ) were seen . 
 laboratory investigation revealed thyrotoxicosis and elevated cardiac markers . 
 six days after starting medical treatment , complete restoration of the left ventricular function was observed . 
 the transient left ventricular dysfunction was induced by thyrotoxicosis resembling stress - induced cardiomyopathy that resolved completely after medical treatment . 
Case report
Conclusion