BackgroundECG criteria differentiating Takotsubo cardiomyopathy (TTC) from mainly anterior myocardial infarction (MI) have been suggested; however, this was in small patient populations.Methods and ResultsTwelve‐lead admission ECGs of consecutive 200 TTC and 200 MI patients were compared in dichotomized groups based on the presence or absence of ST‐elevation MI (STEMI versus STE‐TTC and non‐ST elevation MI versus non ST‐elevation‐TTC). When comparing STEMI and STE‐TTC, ST‐elevation in –aVR was characteristic of STE‐TTC with a sensitivity/specificity of 43% and 95%, positive predictive value (PPV) 91%, and a negative predictive value (NPV) 62% (P<0.001); when ST‐elevation in –aVR is accompanied by ST‐elevation in inferior leads, sensitivity/specificity were 14% and 98% (PPV was 89% and NPV 52%) (P=0.001), and 12% and 100% when associated with ST‐elevation in anteroseptal leads (PPV 100%, NPV 52%) (P<0.001). On the other hand, STEMI was characterized by ST‐elevation in aVR (sensitivity/specificity of 31% and 95% P<0.001, PPV 85% and NPV 59%) and ST‐depression in V2‐V3‐V4 (sensitivity/specificity of 24% and 100% P<0.001, PPV 100% and NPV 76%). When comparing non‐ST elevation MI and non ST‐elevation‐TTC, T‐inversion in leads I‐aVL‐V5‐V6 had a sensitivity/specificity of 17% and 97% for non ST‐elevation‐TTC (PPV 83% and NPV 55%) (P<0.001), and ST‐elevation in –aVR with T‐inversion in any lead was also specific for non ST‐elevation‐TTC (sensitivity/specificity of 8% and 100%, PPV 100% and NPV 53%) (P=0.006). In non‐ST elevation MI patients, the presence of ST‐depression in V2‐V3 was specific (sensitivity/specificity of 11% and 99%, PPV 91% and NPV 51%) (P=0.01).ConclusionsECG on admission can differentiate between TTC and acute MI, with high specificity and positive predictive value.Clinical Trial RegistrationURL: https://www.clinicaltrials.gov/. Unique identifier: NCT01947621.

ZusammenfassungVorgestellt wird der seltene Fall eines Melanoms im Myokard bei gleichzeitigem Vorliegen einer Aortenklappeninsuffizienz bei einem 23jäh-rigen Schimmelwallach. Das Pferd wurde nach einem Sturz, in dessen Folge sich eine geringgradige Koliksymptomatik entwickelte und nach zunehmender Apathie in die Klinik eingewiesen. Bei der klinischen Untersuchung fiel ein holodiastolisches Herzgeräusch dritten Grades auf. Die durch die elektrokardiographische Untersuchung nach Einthoven gemessene Darstellung der QRS-Hauptvektors in der Horizontalebene zeigte eine stark positive Richtung von +115°. Aufgrund ungeklärter echogener Strukturen bei der echokardiographischen Untersuchung wurden Röntgenaufnahmen des Thorax angefertigt. Diese zeigten einen doppelt handflächengroßen radioluzenten, gut abgegrenzten Bereich, der vom Abdomen über das Zwerchfell in die Brusthöhle hineinragte. Wegen des Verdachts auf eine Hernia diaphragmatica wurde das Pferd euthanasiert. Bei der Obduktion und pathohistologischen Untersuchung konnte neben der Zwerchfellshernie, eine ausgeprägte knotige Verdickung des akoronaren Aortenklappensegels, eine Vergrößerung des linken Ventrikels, sowie etwa zwei Zentimeter vom Aortenübergang entfernt ein kirschgroßes Melanom im interventrikulären Septum nachgewiesen werden. Die Ätiologie, Pathogenesse und Zusammenhänge zwischen Aortenklappeninsuffizienz und Myokardmelanom werden erläutert und diskutiert.Schlüsselworter: Myokard, Melanom, Herz, Aortenklappeninsuffizienz, Zwerchellshernie Aortic valve insufficiency and myocardial melanoma in a horseThis report documents the rare case of a myocardial melanoma with concurrent aortic valve insufficiency in a 23 year old grey gelding. The horse was referred to the clinic with the history of a fall, followed by a mild colic episode and increasing depression. During clinical examination a holodiastolic third grades cardiac murmur was detected. By means of electrocardiography and vectoral calculation in the Einthovens triangle a strong positive mean electrical axis of 115 degrees in the frontal plane was observed. Echocardiography did not reveal clear diagnostic findings. Thoracic radiography showed large gasfilled well separated pockets that extended from the abdominal cavity through the diaphragm into the thoracic cavity. The horse was euthanized because a diaphragmatic hernia was suspected. Gross necropsy and histopathology showed a diaphragmatic hernia, a distinct nodular thickening of the valvula semilunaris septalis of the aortic valve, an enlargement of the left ventricle and a melanoma of approximately cherry large in the interventricular septum about 2 cm distant from the aortic valve. Etiology, pathogenesis and correlation of aortic valve insufficiency and melanoma are discussed.

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