It’s a Trap! Clinical Similarities and Subtle ECG Differences between Takotsubo Cardiomyopathy and Myocardial Infarction

Abstract

We describe a 65-year-old woman with a history of hypertension and smoking who presented with an acute episode of chest pain precipitated by severe emotional stress. Her initial electrocardiogram done in the emergency room showed non-specific T wave changes in the lateral leads and her cardiac troponin levels were mildly elevated. Because of her clinical presentation, she was admitted with a presumptive diagnosis of acute myocardial infarction and managed with antiplatelet and anticoagulant therapy. Coronary angiogram did not reveal coronary artery disease and left ventriculography showed findings consistent with apical ballooning syndrome or takotsubo cardiomyopathy. Subsequent electrocardiograms displayed dramatic changes including T wave inversions, QT interval prolongation and U waves. The patient remained asymptomatic and recovered uneventfully. Three weeks post-discharge, an echocardiogram documented resolved left ventricular dysfunction. We describe the clinical features and highlight the electrocardiographic findings that may help differentiate takotsubo cardiomyopathy from myocardial infarction.KEY WORDS: takotsubo cardiomyopathy; apical ballooning; myocardial infarction; electrocardiogram.

Takotsubo cardiomyopathy and microvascular dysfunction

“…Prior literature suggests several reportings that favor this causal association. The presence of predominantly reversible anterior/ anteroseptal or diffuse precordial Q-waves in patients with TC and more recent reports suggesting an association between viral myopericarditis and TC seem to support the hypothesis of microvascular dysfunction and extended epicardial inflammation in the pathogenesis of TC [2][3][4]. One of the prior landmark studies on this subject also demonstrated prolonged TFCs in the left anterior descending and left circumflex coronary arteries in patients with TC as compared to the control population [5].…”

Distinguishing a Heart Attack From the "Broken Heart Syndrome" (Takotsubo Cardiomyopathy)

“…5,6 On electrocardiography, an ST elevation greater than 2 mm usually indicates MI, 7 whereas a higher ST elevation in V 4 YV 6 rather than in V 1 YV 3 , with no Q waves and lack of reciprocal changes, is very indicative of TC, 2,15 as are dynamic and persistent T-wave changes. 15 Nevertheless, ECG alone is insufficient in differentiating TC from MI. 4,5,15 According to a report by Kosuge et al, 16 TC has several other electrocardiographic characteristics distinguishing them from an MI.…”

“…15 Nevertheless, ECG alone is insufficient in differentiating TC from MI. 4,5,15 According to a report by Kosuge et al, 16 TC has several other electrocardiographic characteristics distinguishing them from an MI. Higher number of leads in which the ST segment is elevated is characteristic of TC, most especially in leads I, II, III, aVF, and jaVR (ie, ST depression in aVR).…”

“…The first 3 of the 4 modified Mayo Clinic criteria are as follows: (1) transient hypokinesis, akinesis, or dyskinesis of the left ventricular midsegments with or without apical involvement; regional wall motion abnormalities extending beyond a single epicardial vascular distribution; a stressful trigger (in most cases); (2) absence of coronary vascular disease and no angiographic evidence of plaque disruption; and (3) ST elevation and/or T inversion or modest rise in troponin levels. 2,15 However, some authors proposed that the presence of coronary artery disease should not necessarily exclude TC. 15,19 Computed tomography coronary angiogram and coronary angiography may be used to explore the extent of coronary disease.…”

“…2,15 However, some authors proposed that the presence of coronary artery disease should not necessarily exclude TC. 15,19 Computed tomography coronary angiogram and coronary angiography may be used to explore the extent of coronary disease. 10,20 Advanced atherosclerotic disease was believed to be rare in TC, although in 1 case series, coronary stenosis of 50% or greater was documented in 35% of 20 patients.…”