Takotsubo cardiomyopathy in myasthenia gravis: a systematic review of case reports with subtype-based analysis

BACKGROUND: Takotsubo cardiomyopathy (TTC) is a stress-induced cardiac disorder characterized by transient left ventricular dysfunction. Myasthenia gravis (MG), an autoimmune neuromuscular disease, can precipitate TTC during exacerbations such as myasthenic crises. However, the clinical features and outcomes of TTC associated with MG remain unclear. METHODS: We conducted a systematic review by the PRISMA guidelines. A comprehensive search of PubMed, Web of Science, and Google Scholar was performed up to May 31, 2025, using terms related to TTC and MG. Case reports and series were included if they described patients with confirmed diagnoses of both MG and TTC, with MG exacerbation occurring at the time of TTC onset. Data were extracted and compared between apical and non-apical TTC subtypes. Statistical analyses included the Mann-Whitney U test and chi-squared or Fisher's exact test, as appropriate. RESULTS: A total of 38 articles comprising 40 cases were included. The median age was 69 years; 67.5% of the participants were female. Apical TTC was the most common subtype (71.8%). Myasthenic crisis was the most frequent TTC trigger (37.5%), while chest pain was reported in only 17.5% of cases. Mechanical ventilation and ICU admission were required in 95% and 97.4% of cases, respectively. Overall mortality was 17.5%. No significant differences were found between TTC subtypes; apical cases showed numerically higher troponin levels, which should be interpreted cautiously. CONCLUSIONS: TTC associated with MG exacerbation is a rare but serious condition with high rates of respiratory failure, ICU admission, and mortality. Emergency and critical care physicians should suspect TTC in MG patients presenting with hemodynamic instability or ECG abnormalities, even in the absence of chest pain.