Comparison of Electrocardiographic Findings Between the Midventricular Ballooning Form and Apical Ballooning Form of Takotsubo Cardiomyopathy

Abstract

Background: Several reports have recently described the variant form of takotsubo cardiomyopathy exhibiting midventricular ballooning. The purpose of this study was to assess electrocardiographic (ECG) findings on admission in patients with midventricular ballooning. Hypothesis: ECG findings are different between the midventricular ballooning form and apical ballooning form of takotsubo cardiomyopathy. Methods: We reviewed ECGs on admission in 6 patients with midventricular ballooning and 20 patients with apical ballooning. The sum of ST segment elevation in leads V1 to V3 or in leads V4 to V6 was obtained. The number of leads showing ST segment elevation and/or T wave inversion was also obtained. These ECG findings were compared between the 2 groups. Results: In midventricular ballooning, ECG changes including ST segment elevation and/or T wave inversion were observed frequently in leads V2 and V3, and were not observed in leads II, III, −aVR, aVF, V5, and V6. On the other hand, in apical ballooning, they were found in all leads. They were most common in leads V4 and V5. The sum of ST segment elevation in leads V1 to V3 was similar (2.6 ± 2.0 mm vs 2.7 ± 2.0 mm, P = not significant), and the sum of ST segment elevation in leads V4 to V6 was significantly lower in midventricular ballooning than apical ballooning (0.4 ± 0.8 mm vs 3.5 ± 3.0 mm, P < 0.05). The number of leads showing ST segment elevation and/or T wave inversion was significantly lower in midventricular ballooning than apical ballooning (3.2 ± 1.0 leads vs 6.3 ± 2.2 leads, P < 0.01). Conclusions: Our data suggested that midventricular ballooning may show limited ECG changes despite broad wall motion abnormality. IntroductionA novel cardiac syndrome exhibiting transient left ventricular apical wall motion abnormality (apical ballooning) with chest symptoms and electrocardiographic (ECG) changes has become accepted worldwide as a distinct clinical entity. 1 -8 This disorder has been widely called takotsubo cardiomyopathy. Several reports have recently described its variant form exhibiting midventricular ballooning. 9 -11 In patients with apical ballooning, ECG usually shows ST segment elevation and subsequent T wave inversion with QT interval prolongation during the early stage. However, there is little information about ECG findings in patients with midventricular ballooning. To address this issue, we reviewed ECGs on admission in patients with midventricular ballooning and those with apical ballooning and compared ECG findings between the 2 groups.

Tako-tsubo cardiomyopathy: Clinical presentation and underlying mechanism

“…Recently, apical sparing variant of tako-tsubo cardiomyopathy has been described, occurring in a significant minority of patients with a clinical presentation similar to that of typical tako-tsubo cardiomyopathy [34]. Apical sparing variant of tako-tsubo cardiomyopathy shows limited ECG abnormalities compared to typical tako-tsubo cardiomyopathy [35] (Fig. 7).…”

Clinical Management of Takotsubo Cardiomyopathy

“…Single-photon emission comhave been reported, such as RWMA in the mid segment with apical sparing (apical-sparing variant) (Figure 1) or right ventricular involvement. 17 The apical-sparing variant shows limited ECG changes despite RWMA (Figure 2), 18 and echocardiography plays an important role in the diagnosis of this variant. Echocardiography is also useful in detecting acute complications such as cardiogenic shock because of left ventricular outflow tract (LVOT) obstruction, apical thrombosis or cardiac rupture.…”

“…In the apical-sparing variant, ST-segment elevation is found only in leads V2 and V3. (Adapted with permission from Kurisu S, et al 18 ) Management of Takotsubo Cardiomyopathy injury such as creatine kinase, creatine kinase-MB or troponin. 1-5 Some patients even have normal levels of these biomarkers despite RWMA.…”

Can you interpret the ECG under stress?

“…(22) ECG changes more often affect all leads in apical variants, while only leads V2 and V3 are affected in the mid-ventricular variants. (23) SC can coexist with other pathologies (e.g. acute pericarditis), complicating ECG interpretation.…”