Superimposed Takotsubo syndrome and acute myocardial infarction: a systematic review and pooled analysis of published cases.

Takotsubo syndrome (TTS) has traditionally been regarded as a diagnosis of exclusion requiring the absence of obstructive coronary artery disease. However, increasing evidence suggests that acute myocardial infarction (AMI) and TTS may coexist as a combined overlap phenotype. We refer to this entity as STAMI (Superimposed Takotsubo and Acute Myocardial Infarction). This review summarizes currently available evidence regarding the clinical characteristics, imaging findings, mechanisms, and outcomes of this underrecognized syndrome. A systematic review of published case reports and case series identified 48 patients with simultaneous AMI and TTS reported between 2000 and 2025. The mean age was 67 years and 69% were women. STEMI was present in 57% and NSTEMI in 41% of cases. Although atherosclerotic plaque rupture was the predominant infarct mechanism, vasospasm and spontaneous coronary artery dissection accounted for more than 20% of presentations. A consistent finding across reports was an anatomical-functional mismatch in which wall-motion abnormalities extended beyond the culprit coronary territory, most commonly manifesting as apical ballooning. Marked QTc prolongation and disproportionately elevated natriuretic peptide levels were recurrent features. Initial left ventricular dysfunction was often severe but demonstrated substantial recovery during follow-up, supporting the presence of reversible stress-induced myocardial stunning in addition to ischemic injury. Cardiogenic shock occurred in approximately 10% of patients, while in-hospital mortality was 6.3%. Recognition of STAMI is clinically important because ventricular dysfunction frequently exceeds the expected infarct territory and may influence diagnostic interpretation, risk stratification, and therapeutic management strategies.