RATIONALE: Septic cardiomyopathy (SCM) is a severe and often reversible complication of sepsis but carries a high mortality rate when it progresses to cardiogenic shock. Differentiating SCM from acute coronary syndrome in septic patients is a major clinical challenge. This report details a case of SCM secondary to small intestinal perforation, highlighting both its life-threatening presentation and successful management. PATIENT CONCERNS: A 62-year-old male presented with acute abdominal pain and was found to have a small intestinal perforation with peritonitis. Emergency surgery was performed. Postoperatively, the patient developed profound septic and cardiogenic shock, with ST-segment elevation on the electrocardiogram mimicking an acute anterior myocardial infarction. DIAGNOSES: SCM, septic shock, and cardiogenic shock were diagnosed based on the postsurgical sepsis, ST-segment elevation, significantly elevated troponin levels, and a transthoracic echocardiogram showing a severely reduced left ventricular ejection fraction of 38% with diffuse hypokinesis. INTERVENTIONS: A multimodal strategy was employed, including surgical source control, high-dose vasopressor support, intra-aortic balloon pump insertion, continuous renal replacement therapy to modulate the cytokine storm, and inotropic support with levosimendan. OUTCOMES: The patient's hemodynamics stabilized, and cardiac function showed significant recovery, with left ventricular ejection fraction improving to 65%. The ST-segment changes resolved. He was successfully weaned from all supports and discharged. LESSONS: This case highlights the diagnostic pitfall of SCM mimicking ST-segment elevation myocardial infarction. It demonstrates that early recognition, definitive source control, and a comprehensive, multimodal support strategy are critical for a favorable outcome, even in life-threatening SCM.