Takotsubo-Like Syndrome Due to Microvascular Dysfunction in a Transgender Woman Under Gender-Affirming Hormone Therapy.

BACKGROUND: A 45-year-old Black transgender woman on long-term estrogen therapy presented with chest pain and progressed to ventricular fibrillation and cardiac arrest. Initial electrocardiogram revealed ST-segment elevation in leads V1 to V2, consistent with an anteroseptal myocardial infarction. CASE SUMMARY: The patient was referred for coronary angiography within 24 hours of symptom onset, showing no epicardial obstruction and apical akinesia on ventriculography, suggestive of Takotsubo syndrome. Cardiac magnetic resonance imaging ultimately revealed transmural infarction with extensive microvascular obstruction. DISCUSSION: Microvascular dysfunction can underlie Takotsubo-like cardiomyopathies, particularly in acute, prothrombotic states. Although well described in cisgender women, its presentation in gender-diverse populations is poorly reported. TAKE-HOME MESSAGES: Takotsubo-like syndrome may present with life-threatening arrhythmias and its main cause is myocardial infarction, especially due to microvascular obstruction. This case illustrates a severe myocardial infarction with nonobstructive coronary arteries-related Takotsubo-like syndrome, highlighting diagnostic challenges and the importance of multimodal imaging.