A new ECG criterion to identify takotsubo cardiomyopathy from anterior myocardial infarction: role of inferior leads. Heart Vessels. 2009;24:124-130. [PMID: 19337796 DOI: 10.1007/s00380-008-1099-9]

The impact of ST-segment elevation on the prognosis of patients with Takotsubo cardiomyopathy

INTRODUCTION

Takotsubo cardiomyopathy (TC) has a variety of electrocardiographic expressions such as ST-segment elevation (STE), T-wave inversion, QTc-prolongation, left bundle branch block, presence of anterior Q waves and rarely ST-segment depression. In contrast to acute myocardial infarction, the impact of STE on the initial electrocardiogram (EKG), on TC outcomes, remains largely unknown.

OBJECTIVE

To evaluate the significance of STE on the index EKG of patients with takotsubo cardiomyopathy (TC) in terms of prognosis.

METHODS

We examined retrospectively the data of 436 patients diagnosed with TC who were admitted to the Minneapolis Heart Institute between August 2001 and November 2019.

RESULTS

Of 436 patients, 145 (33%) presented with STE on the index EKG. Typical apical ballooning pattern was encountered more frequently in the STE group (66% vs 51%; p = 0.005), on the contrary to the mid-ventricular ballooning which was more common in the non-STE group (31% vs 45%; p = 0.005) while initial left ventricular ejection fraction was similar between the two groups (31% ± 9 vs 33% ± 11; p = 0.163). The composite endpoint of TC-related complications, defined as left ventricular outflow tract obstruction (LVOTO), left ventricular (LV) thrombus, hemodynamic instability requiring mechanical or intravenous vasopressor support, cardiac arrest or in-hospital death, was higher for the STE group (37% vs 24%; p = 0.006). Left ventricular outflow obstruction (LVOTO) was more frequent in patients with STE (13% vs 3%; p < 0.001) while there was a trend toward higher rates of LV thrombus formation in the same group (5% vs 1%; p = 0.057). On multivariable analysis, STE remained an independent predictor of TC-related complications. In-hospital mortality (2.8% vs 3.4%; p = 1.000) and five-year mortality were similar between the two groups (23% vs 20%; p = 0.612).

CONCLUSION

Patients with TC presenting with STE on the initial EKG, were more likely to develop disease related complications, thus, careful in-hospital monitoring including imaging evaluation for LVOTO and LV thrombus may be warranted for these patients. Nevertheless, both groups had similar in-hospital and five-year mortality.

Machine learning of microvolt-level 12-lead electrocardiogram can help distinguish takotsubo syndrome and acute anterior myocardial infarction

Background

Methods

Results

Conclusion

ECG differences and ECG predictors in patients presenting with ST segment elevation due to myocardial infarction versus takotsubo syndrome

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Takotsubo syndrome and myocardial infarction can present with ST segment elevation.

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ECG in Takotsubo resembles left anterior descending artery myocardial infarction.

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Ventricular arrhythmia or death occur in both Takotsubo and myocardial infarction.

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ST segment changes predict ventricular arrhythmia or death in myocardial infarction.

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ST segment changes do not predict ventricular arrhythmia in Takotsubo syndrome.

Background

Previous studies comparing electrocardiogram (ECG) in Takotsubo syndrome (TS) versus ST elevation myocardial infarction (STEMI) included TS patients without ST elevation, did not consider the culprit lesion in STEMI or had groups that were unbalanced regarding sex and age. Accounting for these factors, we sought to conduct a more reliable comparison of ECG in TS with ST-elevation (STE-TS) versus STEMI. The secondary aim was to investigate if ST segment changes, T wave inversion or prolonged QT interval predicted ventricular arrhythmia or death in STE-TS and STEMI.

Methods

All STE-TS patients who presented at Sahlgrenska University Hospital between 2008 and 2019 were matched by sex and age to STEMI patients. STEMI patients were subcategorized according to whether or not the culprit lesion was located in the left anterior descending artery (LAD). Baseline characteristics, in‐hospital outcomes and admission ECGs were analyzed.

Results

104 STE-TS patients were sex- and age-matched with 274 STEMI patients (113 LAD-STEMI, 161 non-LAD STEMI). Admission ECG in STE-TS was more similar to LAD STEMI than non-LAD STEMI. Reciprocal ST depression was less common in STE-TS (7/104, 6.7%) compared with STEMI (112/274, 41%; p= < 0.001). The sum of all ST elevations and the sum of all ST-deviations predicted life-threatening ventricular arrhythmia (LTVA) or death in LAD STEMI but not in STE-TS.

Conclusions

In conclusion, admission ECG in STE-TS was similar to LAD STEMI but reciprocal ST depression was less common in STE-TS compared with STEMI overall. ST segment changes predicted LTVA or death in STEMI but not in STE-TS.

Pathophysiology of Takotsubo Syndrome as A Bridge to Personalized Treatment

Takotsubo syndrome (TTS) consists of transient dysfunction of the left and/or right ventricle in the absence of ruptured plaque; thrombus or vessel dissection. TTS may be divided into two categories. Primary TTS occurs when the cause of hospitalization is the symptoms resulting from damage to the myocardium usually preceded by emotional stress. Secondary TTS occurs in patients hospitalized for other medical; surgical; anesthetic; obstetric or psychiatric conditions who have activation of their sympathetic nervous system and catecholamines release- they develop TTS as a complication of their primary condition or its treatment. There are several hypotheses concerning the cause of the disease. They include a decrease in estrogen levels; microcirculation dysfunction; endothelial dysfunction and the hypothesis based on the importance of the brain-heart axis. More and more research concerns the importance of genetic factors in the development of the disease. To date; no effective treatment or prevention of recurrent TTS has been found. Only when the pathophysiology of the disease is fully known; then personalized treatment will be possible.

Electrocardiographic changes in Takotsubo cardiomyopathy

Takotsubo Cardiomyopathy (TC) is a syndrome characterized by reversible left ventricular dysfunction in the presence of possible emotional or physical triggers but without evidence of obstructive coronary artery disease. It has become increasingly reported worldwide and is associated with significant morbidity and mortality. TC may present with an array of electrocardiographic (ECG) findings. These ECG findings, if accurately interpreted, can play an important role in the diagnosis and risk stratification of this syndrome. In the last three decades since the disease was first described, multiple diagnostic criteria have been established. The key diagnostic tools for TC include clinical symptomatology, cardiac biomarkers, non-invasive cardiac imaging, and coronary angiography. The ECG findings in TC can be variable, however, some ECG scores have been proposed in association with TC with reasonably good diagnostic sensitivity and specificity. This article aims to provide a succinct review of important electrocardiographic findings associated with TC and its impact on clinical outcomes.

[Clinical Manifestation of Stressful Cardiomyopathy (Takotsubo Syndrome) and the Problem of Differential Diagnosis with Acute Myocardial Infarction]

The presented data show that tacotsubo syndrome (TS) is characterized by the absence of coronary artery obstruction, cardiac contractile dysfunction, apical ballooning, and heart failure, and in some patients, ST-segment elevation and prolongation of the QTc interval. Every tenth patient with TS develops ventricular arrhythmias. Most of TS patients have elevated markers of necrosis (troponin I, troponin Т, and creatine kinase МВ (CK-МВ), which are considerably lower than in patients with acute myocardial infarction (AMI) with ST-segment elevation. The level of N-terminal pro-B-type natriuretic peptide (NT-proBNP), in contrast, is considerably higher in patients with TS than with AMI. Differential diagnosis of TS and AMI should be based on a multifaceted approach using coronary angiography, echocardiography, analysis of ECG, magnetic resonance imaging, single-photon emission computed tomography, and measurement of troponins, CK-MB, and NT-proBNP.

Takotsubo syndrome vs anterior STEMI electrocardiography; a meta-analysis and systematic review

BACKGROUND

Takotsubo syndrome (TTS) and its differentiation from anterior wall ST-elevation myocardial infarction on electrocardiography (ECG) has been a debate.

METHODS

Six studies comparing ECG changes in TTS and AW-STEMI were identified. The primary endpoint was reciprocal changes, presence of Q-waves, and QT-interval. An unadjusted odds ratio (OR) with a 95% confidence interval (CI) was calculated using Review Manager (RevMan) 5.3.

RESULTS

Six studies consisting of 1090 patients (TTS = 220, AW-STEMI = 870) were included. Reciprocal changes on ECG were less commonly associated with TTS than AW STEMI with OR of 0.05 and 95%CI- 0.02-0.11 (P-<0.00001). Q-wave presence on ECG was comparable between the groups with OR-0.68, 95%CI-0.08-5.63 (p-0.72). QT interval on ECG was comparable between the two groups with OR-1.09, 95%CI-0.63-1.54 (p-<0.00001). There was minimal publication bias among the studies.

CONCLUSION

AW STEMI is associated with reciprocal changes. Q-waves and QT interval has no differentiating significance between AW STEMI and TTS.

Tension pneumothorax-induced Takotsubo syndrome: A case report

RATIONALE

Takotsubo syndrome (TTS) is a form of acute and usually reversible heart failure syndrome. Transient left ventricular dysfunction and electrocardiographic changes could mimic acute coronary syndrome but there are actually no obstructive coronary lesions.

PATIENT CONCERNS

A 76-year-old woman with chronic lung disease developed spontaneous tension pneumothorax with the presentation of severe dyspnea, respiratory failure, left ventricular dysfunction, and anterior wall ST-segment elevation on 12-lead electrocardiogram. Acute coronary syndrome was excluded by normal coronary angiograms.

DIAGNOSIS

The patient was diagnosed as tension pneumothorax complicated by TTS.

INTERVENTIONS

The woman underwent tubal thoracostomy for tension pneumothorax-induced obstructive shock. However, the patient further underwent ligation bullectomy for persistent air leakage 2 weeks later.

OUTCOMES

The left ventricular dysfunction recovered 1 week after resolution of tension pneumothorax. Anterior wall ST-segment elevation resolved 25 days after admission.

LESSONS

Concurrent electrocardiograms and echocardiographic serial evaluations should be performed to provide more comprehensive information when dealing with tension pneumothorax patients.

Electrocardiographic and Seasonal Patterns Allow Accurate Differentiation of Tako-Tsubo Cardiomyopathy from Acute Anterior Myocardial Infarction: Results of a Multicenter Study and Systematic Overview of Available Studies

Background. Though several studies about prevalence, etiology, clinical characteristics, preceding events, clinical management, and outcome of Tako-Tsubo cardiomyopathy (TTC) exist, the current knowledge of TTC remains limited. Objective. In 2006, TTC was classified among the acquired forms of cardiomyopathy. On the basis of pathophysiological implications, we analyzed whether the presence of ST-segment elevation in lead -aVR (i.e., ST-segment depression in aVR) and the simultaneous absence of ST-segment elevation in lead V1 allow a reliable differentiation of TTC from acute anterior ST-segment elevation myocardial infarction (STEMI). A further investigative feature is the seasonal variation of TTC. Since acute cardiovascular events exhibit definite chronobiological patterns, various small studies have tried to evaluate whether this is also the case for TTC. Because results are conflicting, we also conducted a multicenter study and analyzed the findings in context with a systematic overview of available studies. Methods. We compared the ECG patterns of 115 patients with TTC, who were admitted to five large acute cardiac care centers associated with university hospitals in Southwestern Germany between January 2001 and June 2011, with those of 100 patients with acute anterior ST-segment elevation myocardial infarction (STEMI) treated in one of these centers. In addition, we performed a computer-assisted MEDLINE search of the literature from January 2000 to September 2011 and analyzed the chronobiological patterns of available TTC cases, including our TTC cohort. Results. Testing the predefined diagnostic criteria was superior to any other electrocardiographic finding and differentiated TTC from anterior STEMI with a sensitivity of 73%, a specificity of 84%, a positive predictive value of 63%, and a negative predictive value of 89%. Beyond that, the onset of TTC showed a clear variation as a function of season and month. While events occurred most frequently during summer (38.4%, p < 0.01), the event rate was the lowest in autumn (16.4%) and winter (21.9%). Chronobiological analyses on a monthly basis identified a significant annual rhythmic pattern in TTC, which peaked in August (11.9%; p < 0.01) and had its nadir in November (6.3%). Conclusions. Our data illustrate that the ST-segment changes in leads aVR and V1 represent a simple and accurate ECG criterion to differentiate TTC from anterior STEMI in patients who are admitted within 12 h of symptom onset. Similarly, the results of our seasonal analysis indicate a distinct chronobiological variation in TTC occurrence. TTC, thereby, differs from major acute cardiovascular diseases, especially acute myocardial infarction (AMI), which is characterized by winter peaks and troughs in summer. If these results are confirmed in large independent cohorts, they may yield diagnostic implications, changing the regular invasive AMI management in TTC patients.

Takotsubo Cardiomyopathy Mimicking Stent Thrombosis After Percutaneous Coronary Intervention

Takotsubo cardiomyopathy, also known as “broken heart syndrome,” is a transient left ventricular dysfunction associated with stress (usually emotional) induced myocardial injury and stunning. It often presents as myocardial infarction on surface electrocardiogram (EKG). Diagnosis is made by coronary angiography, which rules out coronary artery disease and shows pathognomonic apical ballooning. In this article, we present a case of a 72-year-old woman who initially presented with an ST segment elevation myocardial infarction on EKG. Coronary angiography showed severe left anterior descending artery and diagonal lesions requiring percutaneous coronary intervention. Post–percutaneous coronary intervention, EKG changes resolved. The next day, the patient developed recurrent chest pain and her EKG showed diffuse T-wave inversion in precordial leads with reemerging ST segment elevations concerning for stent thrombosis. The patient underwent repeat emergent coronary angiography, which showed patent stents and findings consistent with takotsubo cardiomyopathy.

The ECG in the differential diagnosis between takotsubo cardiomyopathy and acute coronary syndrome

INTRODUCTION

Takotsubo cardiomyopathy (TC) is an acquired cardiomyopathy affecting mostly postmenopausal women mimicking an acute coronary syndrome (ACS). TC clinical presentation involves chest pain, elevated cardiac enzymes, wall motion abnormalities and electrocardiographic changes, all of which share striking similarities to ACS. Areas covered: Differential diagnosis between TC and ACS can be complex since there are no reliable and widely-accepted electrocardiographic criteria and, at the moment, only coronary angiography can rule out one of the two diagnoses with good certainty. The present review will discuss the pros and cons of the ECG in TC, focusing on how the signal changes through the acute phase, the hospitalization, and after discharge. Specific information will be provided for each component of the ECG trace, and potential pitfalls will be highlighted, in order get to the core of this important unmet clinical issue. Expert commentary: There are at least several reasons why the ECG is still not considered a useful tool in differential diagnosis between TC and ACS. These include recent awareness of the syndrome, lack of evidence-based therapy, and, more importantly, a wide range of ECG features according to race, patient characteristics, wall motion abnormalities, triggers, and time from symptoms onset.

Takotsubo syndrome: Advances in the understanding and management of an enigmatic stress cardiomyopathy

Takotsubo cardiomyopathy is a syndrome mimicking an acute myocardial infarction in absence of obstructive epicardial coronary artery disease to explain the degree of the wall motion abnormalities. Typically more common in the elderly women, this condition is usually triggered by unexpected emotional or physical stress situations, and is associated with electrocardiogram abnormalities and slight elevation of cardiac biomarkers. The pathophysiological mechanism is not clear yet, but it is believed that a high circulating concentration of catecholamines causes an acute dysfunction of the coronary microcirculation and metabolism of cardiomyocytes, leading to a transient myocardial stunning. Typically, it presents with acute left ventricular systolic dysfunction that in most cases is completely resolved at short term. Recurrences are rare and it is thought that the long-term prognosis is good. We present here a review of the clinical features, pathophysiology and management of this enigmatic condition.

ECG Criteria to Differentiate Between Takotsubo (Stress) Cardiomyopathy and Myocardial Infarction

BACKGROUND

ECG criteria differentiating Takotsubo cardiomyopathy (TTC) from mainly anterior myocardial infarction (MI) have been suggested; however, this was in small patient populations.

METHODS AND RESULTS

Twelve-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).

CONCLUSIONS

ECG on admission can differentiate between TTC and acute MI, with high specificity and positive predictive value.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01947621.

Usefulness of ECG to differentiate Takotsubo cardiomyopathy from acute coronary syndrome

OBJECTIVE

We aimed to describe the evolution of ECG changes in TC compared with MI, and evaluate ECG features which might help to distinguish between these conditions.

BACKGROUND

Takotsubo cardiomyopathy (TC) can mimic both ST-elevation (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) but management is different. Several electrocardiographic (ECG) abnormalities have been identified which might help to differentiate TC with and without ST-elevation, from STEMI and NSTEMI, respectively.

METHODS

We prospectively identified 100 consecutive patients with TC and 100 MI patients. They were divided into 2 groups according to the presence of ST-segment elevation (STE). Serial ECGs from admission to Day 2 were compared.

RESULTS

Thirty-five TC patients had STE on admission. Compared with STEMI patients they had less prominent STE (median peak elevation 2mm vs. 3mm, P<0.05), less reciprocal ST-segment depression and no abnormal Q-waves. By Day 2 all STEMI patients had pathological Q-waves but none of the TC patients. Compared with NSTE-TC patients, NSTEMI patients had more ST-segment depression (28.2% vs. 0%, P<0.05), but less T-wave inversion (33.8% vs. 11.3%, P<0.05) on admission. By Day 2 the ECG criterion which best distinguished NSTE-TC from NSTEMI was the presence of T-wave inversion in ≥6 leads (sensitivity 74%, specificity 92%).

CONCLUSION

ECG changes seen in TC within two days of presentation are distinctive and important clues for clinicians to suspect the diagnosis.

"Reverse McConnell's Sign": Interpreting Interventricular Hemodynamic Dependency and Guiding the Management of Acute Heart Failure during Takotsubo Cardiomyopathy

Although most patients with Takotsubo cardiomyopathy (TTC) have benign clinical course and prognosis, TTC can induce acute heart failure and hemodynamic instability. TTC mimics the clinical features of acute anterior wall myocardial infarction (AMI). Bedside clinicians often have a diagnostic dilemma when cardiac catheterization and angiography are either contraindicated or can cause potential adverse consequences. Misdiagnosing TTC as AMI will lead to initiation of harmful pharmacological or device-based treatment, which worsens hemodynamic compromise. Therefore, understanding and interpreting the unique pathophysiological and hemodynamic features of TTC in a better manner becomes crucial to guide effective clinical management of acute heart failure/cardiogenic shock during TTC. We review recent advances in echocardiographic diagnosis of TTC and its role in guiding bedside management of acute heart failure and cardiogenic shock, with specific focus on the interpretation of discrepant, but reciprocally dependent, left and right ventricular hemodynamics during acute stages of TTC.

Diagnosis of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy, also known as left ventricular apical ballooning syndrome and stress-induced cardiomyopathy, is typically characterized by transient systolic dysfunction of the apical and mid-segments of the left ventricle, in the absence of obstructive coronary artery lesions. Patients may present with symptoms and signs of acute coronary syndrome, and the provider is challenged to differentiate between these conditions. In this review, we guide the reader through the diagnostic pathway, focusing on differential diagnoses and diagnostic criteria for takotsubo cardiomyopathy.

Tako-tsubo cardiomyopathy: how to understand possible pathophysiological mechanism and the role of (123)I-MIBG imaging

Tako-tsubo cardiomyopathy (TCM) is an increasingly recognized clinical syndrome characterized by acute reversible apical ventricular dysfunction, commonly preceded by exposure to severe physical or emotional stress. In this review, we give a short overview on clinical presentation and treatment of TCM and discuss the possible pathophysiological mechanisms of TCM and the role of various non-invasive imaging modalities in TCM with a focus on the potential role of (123)I-meta-iodobenzylguanidine (MIBG) scintigraphy. Currently, the dominating hypothesis on the pathophysiology of TCM postulates that high levels of the neurotransmitter epinephrine may trigger a change in intracellular signaling in ventricular myocytes. More specific, epinephrine stimulates G-protein coupled β2 adenoreceptors (β2AR) which are located on ventricular myocytes. Normal levels of this neurotransmitter predominantly stimulate the intracellular G-protein, and induce a positive inotropic effect. However, with significant increasing levels of epinephrine, the predominance of stimulation is shifted from G-stimulating to the G-inhibitor protein coupling, which leads to a negative inotropic effect. Interestingly, this negative inotropic effect is the largest in the apical myocardium where the β2AR:β1AR ratio is the highest within the heart. Echocardiography and ventriculography are essential to diagnose TCM, but new imaging tools are promising to diagnose TCM and to evaluate therapeutic efficacy. Cardiovascular magnetic resonance can be used to differentiate TCM from other myocardial diseases, such as myocarditis. (123)I-meta-iodobenzylguanidine ((123)I-MIBG) scintigraphy can be used to assess ventricular adrenergic activity and may guide optimization of individual (pharmacological) therapy. These new insights into the possible pathophysiological mechanisms and novel diagnostic imaging modalities can be used as starting point for the development of international guidelines of TCM which may increase the awareness, and optimize the treatment of TCM.

Differences in ST-elevation and T-wave amplitudes do not reliably differentiate takotsubo cardiomyopathy from acute anterior myocardial infarction

BACKGROUND

Previous efforts to distinguish acute anterior ST-elevation myocardial infarction (anterior-STEMI) from various forms of takotsubo cardiomyopathy (TTC) by electrocardiography (ECG) have produced differing results.

METHODS

We performed a retrospective comparison of acute ECGs between 48 apical and 9 mid-ventricular TTC patients, with 96 anterior-STEMI patients. ECG was recorded in acute phase (<24h from onset of pain), and analyzed for ST-changes, negative T-waves, abnormal Q-waves and QT-interval duration. Time from onset of pain to ECG was gathered from patient records.

RESULTS

Anterior-STEMI patients had ST-elevation in lead V1 more frequently than apical (70% vs 15%, p<0.0001) or mid-ventricular TTC patients (70% vs 0%, p<0.0001), and higher ST-elevation amplitudes in leads V2-V5 (p<0.02). Lack of ST-elevation in lead V1 and ST-elevation amplitude <2mm in lead V2 distinguished TTC from anterior-STEMI patients with 63% sensitivity and 93% specificity, with 79% predictive value.

CONCLUSIONS

In patients with anterior ST-elevation and acute chest pain, lack of ST-elevation in lead V1 and ST-elevation amplitude <2mm in lead V2 suggests a TTC diagnosis. However, this criterion is not reliable enough in clinical practice to distinguish between TTC and anterior-STEMI patients.

Postoperative takotsubo cardiomyopathy: an illustration of the electrocardiographic features that raise suspicion for takotsubo

Takotsubo cardiomyopathy is an increasingly recognized clinical disorder mimicking acute coronary syndrome. It is usually preceded by physical or emotional stress and recovery of the left ventricular systolic function occurs in most cases within 1–4 weeks. Takotsubo cardiomypathy can masquerade as ST-segment elevation myocardial infarction when chest pain, ST-segment elevation, and high cardiac biomarkers coexist. ST-segment elevation is encountered in approximately half of the cases of takotsubo cardiomyopathy and its pattern is indistinguishable at times from ST-segment elevation myocardial infarction. However, several electrocardiographic criteria have been shown to characterize takotsubo cardiomyopathy. Awareness of these electrocardiographic features has several diagnostic and therapeutic implications. Nevertheless, these electrocardiographic criteria alone cannot reliably differentiate between both entities, and the diagnosis of takotsubo cardiomyopathy is only established after coronary angiography confirms the absence of occlusive coronary artery disease and the characteristic apical ballooning is evident on left ventriculogram (in the case of the apical form). Herein, we present a case of postoperative takotsubo cardiomyopathy and discuss the various electrocardiographic features that raise suspicion for this transient cardiac syndrome.

Transient attenuation of the amplitude of the QRS complexes in the diagnosis of Takotsubo syndrome

BACKGROUND AND OBJECTIVES

Currently, there are no specific diagnostic electrocardiogram (ECG) signs for Takotsubo syndrome (TTS) to differentiate it from acute coronary syndromes (ACS). Myocardial oedema has been detected by cardiac magnetic resonance imaging in patients with TTS. Recently it has been postulated that myocardial oedema may be the cause of low QRS voltage (LQRSV) in the admission ECG and attenuation of the amplitude of the QRS complexes (AAQRS) in serial ECGs, noted in a few published cases of patients with TTS. The objective of this study was to evaluate whether the admission ECG of patients with documented TTS reveals LQRSV and whether AAQRS is found when serial ECGs are compared in such patients.

METHODS

This study evaluated the prevalence of LQRSV in the admission ECG and AAQRS in serial ECGs in patients with TTS. ECGs of 368 patients with TTS from published reports in the international literature were evaluated for LQRSV (≤5 mm in limb leads and/or ≤10 mm in precordial leads) and AAQRS in serial ECGs.

RESULTS

LQRSV was seen in 91.5% of 200 patients with TTS and one ECG, with a distribution of 49.0, 42.8, 51.0, 52.0, and 46.9%, in lead aVR, and inferior, anterior, lateral, and high lateral ECG lead groups, respectively. AAQRS was seen in 93.5% of 168 patients with TTS and two or more ECGs, with a distribution of 78.3, 74.5, 60.1, 70.7, and 74.5% in lead aVR, and inferior, anterior, lateral, and high lateral ECG lead groups, respectively.

CONCLUSIONS

LQRSV and AAQRS are highly prevalent ECG signs in patients with TTS, and should be useful in aiding in its diagnosis and differentiation from ACS, on first contact with the patient on admission to the hospital, and the ensuing 24 hours, in conjunction with echocardiography and coronary arteriography.

When a broken heart is real: Takotsubo cardiomyopathy

Takosubo cardiomyopathy is a rare but reversible type of cardiomyopathy that often mimics symptoms of acute coronary syndromes. It is essential that NPs differentiate the causes because treatment strategies vary.

Apical ballooning syndrome (takotsubo cardiomyopathy) after permanent dual-chamber pacemaker implantation

Apical ballooning syndrome, also called takotsubo cardiomyopathy, has been recently reported. It may mimic acute myocardial infarction and is typically observed in postmenopausal women after stressful events. A 75-year-old female after permanent dual chamber pacemaker implant complained of chest pain with repolarization alterations suggesting acute myocardial ischemia. Echocardiography showed a left ventricle with akinesia of the apical portions and reduced global systolic function. The patient was treated with antithrombotic agents and intravenous nitrates. No coronary lesions were found at angiography. At ventriculography, a typical takotsubo-like shape of the left ventricle was observed. The clinical and echocardiographic picture normalized at discharge.

Takotsubo cardiomyopathy: an Australian single centre experience with medium term follow up

BACKGROUND

Takotsubo cardiomyopathy (TC) is increasingly recognised in patients presenting with features of acute coronary syndrome. We present a single centre experience of TC with medium term follow up.

METHODS

Fifty-two consecutive patients presenting with a diagnosis of TC were included. The clinical presentation, complications, baseline and follow-up echocardiograms and cardiac magnetic resonance imaging were analysed.

RESULTS

Fifty-one patients were female. A stressful event preceded presentation in 37 (71%) patients. Chest pain was the most common symptom (83%). Two patients presented with an out-of-hospital cardiac arrest. ST segment elevation (40%) and global T wave inversion (44%) were the most frequent electrocardiogram changes. Left ventricular assessment demonstrated typical apical ballooning in 41 patients and 11 patients demonstrated the mid-wall variant. In-hospital complications occurred in 11 patients (21%) and included acute pulmonary oedema (n = 2), cardiogenic shock (n = 5); two of whom had a significant left ventricular outflow gradient, atrial fibrillation (n = 1), left ventricular thrombus (n = 2) and a cerebrovascular event (n = 2). Left ventricular function at presentation and follow up was compared in 40 patients. The mean ejection fraction in this group at presentation was 47% (20-70%) compared with that at follow up of 63% (44-76%). There were no significant complications or recurrences at follow up.

CONCLUSIONS

While TC is a reversible condition with low rates of complications and recurrence at follow up it is, as demonstrated in our cohort, associated with significant in-hospital morbidity in a proportion of patients.

Acute coronary syndrome or apical ballooning syndrome?

Apical ballooning syndrome (ABS) is uniquely characterized by the acute onset of transient extensive kinesis of the apical and mid portions of the left ventricle without significant epicardial coronary artery stenosis, accompanied by chest symptoms and electrocardiogram changes similar to those of acute coronary syndrome. We report a case of ABS with severe coronary artery stenosis presenting as acute coronary syndrome after emotional stress. ABS should be considered a cause of left ventricular wall motion abnormalities even if a coronary arteriogram shows severe coronary artery stenosis.

Stress cardiomyopathy: diagnosis, pathophysiology, management, and prognosis

Stress cardiomyopathy is now a well-recognized reversible cardiomyopathy, with a clinical presentation mimicking Acute Coronary syndrome in the absence of significant coronary artery disease. It is often encountered in postmenopausal females and is usually precipitated by acute emotional or physical stressors. In this review, we have attempted to summarize relevant data regarding diagnosis, typical and atypical presentations, pathophysiology, management options, and prognosis. Typically, patients present with chest pain and shortness of breath, transient electrocardiographic changes, moderate troponin elevation, and are found to have wall motion abnormalities (apical and midventricular akinesis with preserved basal segment systolic function) without obstructive coronary lesions, with complete resolution in next few weeks. The precise pathophysiology remains unclear, but excessive catecholamine stimulation, metabolic disturbances, and dysfunction of microcirculation are thought to be the underlying mechanisms.

A new electrocardiographic criterion to differentiate between Takotsubo cardiomyopathy and anterior wall ST-segment elevation acute myocardial infarction

Several studies have examined the ability of electrocardiography to differentiate between takotsubo cardiomyopathy (TC) and anterior wall acute ST-segment elevation myocardial infarction (AA-STEMI). In those studies, the magnitude of ST-segment elevation was not measured at the J point. The American Heart Association, American College of Cardiology Foundation, and Heart Rhythm Society guidelines recommend that the magnitude of ST-segment elevation should be measured at the J point. Accordingly, the aim of this study was to retrospectively examine whether electrocardiography, using the magnitude of ST-segment elevation measured at the J point, could differentiate 62 patients with TC from 280 with AA-STEMI. Patients with AA-STEMI were divided into following subgroups: 140 with left anterior descending coronary artery occlusions proximal to the first diagonal branch (AA-STEMI-P), 120 with left anterior descending occlusions distal to the first diagonal branch and proximal to the second diagonal branch (AA-STEMI-M), and 20 with left anterior descending occlusions distal to the second diagonal branch (AA-STEMI-D). TC had a much lower prevalence of ST-segment elevation ≥1 mm in lead V(1) (19.4%) compared to AA-STEMI (80.4%, p <0.01), AA-STEMI-P (80.7%, p <0.01), AA-STEMI-M (80%, p <0.01), and AA-STEMI-D (80%, p <0.01). ST-segment elevation ≥1 mm in ≥1 of leads V(3) to V(5) without ST-segment elevation ≥1 mm in lead V(1) identified TC with sensitivity of 74.2% and specificity of 80.6%. Furthermore, this criterion could differentiate TC from each AA-STEMI subgroup, with similar diagnostic values. In conclusion, using the magnitude of ST-segment elevation measured at the J point, a new electrocardiographic criterion is proposed with an acceptable ability to differentiate TC from AA-STEMI.

An unusual electrocardiographic manifestation of Takotsubo cardiomyopathy

An elderly Malay lady presented with lethargy and 2-day history of chest pain. Her electrocardiogram showed diffuse concave ST-segment elevation with depressed PR segments. Coronary angiogram was normal. The left ventriculogram demonstrated apical akinesis with hyperdynamic contraction of the basal segments consistent with feature of Takotsubo cardiomyopathy. This case highlights an uncommon electrocardiogram presentation of Takotsubo cardiomyopathy.

Performance of electrocardiographic criteria to differentiate Takotsubo cardiomyopathy from acute anterior ST elevation myocardial infarction

BACKGROUND

The initial electrocardiogram (ECG) in Takotsubo cardiomyopathy (TC) can mimic an acute, anterior ST-segment elevation myocardial infarction (STEMI). Given the profound and immediate treatment differences between TC and STEMI, it would be clinically valuable to distinguish them using ECG criteria.

METHODS

Presenting ECGs for proven cases of TC and acute, anterior STEMI were retrospectively collected. QRS onset and J-point were manually identified using custom software to compute median ST deviation for each lead. Six published ECG criteria were examined for diagnostic accuracy using the clinical diagnosis as the gold standard.

RESULTS

33 TC and 263 acute, anterior STEMI cases were identified. ST-segment deviation differed significantly between groups for all leads except aVR, I, V5, and V6. All six published ECG criteria showed a marked reduction in diagnostic accuracy in our validation cohort, except for a combination of ST-elevation in leads V2<1.75 mm and V3<2.5 mm (sensitivity 79%, specificity 73% for TC).

CONCLUSION

Our study demonstrates the limited diagnostic accuracy of published ECG rules to distinguish TC from acute, anterior STEMI. Given the rarity of TC and the clinical consequences of a "false positive" TC diagnosis based on ECG criteria alone, such rules should not be used in practice. TC remains a diagnosis of exclusion after emergent angiography in patients with an acute coronary syndrome and significant ST-segment elevation.

Arrhythmia occurrence with takotsubo cardiomyopathy: a literature review

AIMS

Takotsubo cardiomyopathy (TC) or the apical ballooning syndrome is a reversible cardiomyopathy mimicking acute myocardial infarction (AMI). Although malignant arrhythmia is considered less likely to occur in TC than with AMI, sporadic reports of malignant arrhythmia with TC, however, have been reported. We reviewed the medical literature on TC and arrhythmias and describe in the summary the reported findings and discuss possible specific scenarios where arrhythmia may be more likely in patients with TC.

METHODS AND RESULTS

Articles were identified on PubMed using the MeSH terms 'Takotsubo Cardiomyopathy' or 'Apical Ballooning Syndrome'. Seventy-four unique case series with five or more TC patients were identified, with a cumulative total of 1876 cases. Twelve series (242 cases) were excluded because Mayo criteria were not met. Twenty-five series (816 cases, 43.5%) reported on arrhythmia and were included in the analysis.

CONCLUSION

Areas for further prospective study include the duration and mechanism of residual risk and optimal risk stratification and modification. The current state of evidence would support beta-blockers in the acute setting to control tachyarrhythmia, although there is little evidence to support their use beyond convalescence when used for this indication alone. Those in heart failure and cardiogenic shock should be managed with established evidence-based therapies for these conditions. The use of internal defibrillators in TC requires consideration only on a case-by-case basis.

Cardiac and vascular gene profiles in an animal model of takotsubo cardiomyopathy

We investigated cardiac and vascular gene profiles in response to immobilization stress (IMO) in rats, an animal model of emotional stress-induced takotsubo cardiomyopathy using microarray analysis, followed by re-confirmation with real-time reverse transcription-polymerase chain reaction. Expression levels of the identified genes were further estimated by pretreatment with an α1-adrenoceptor blocker and/or a β1-adrenoceptor blocker. In response to IMO, expression of 46 genes was significantly altered in the heart and that of 49 genes was significantly altered in the aorta. Pathway analysis with DAVID Bioinformatics Resources indicated that regulation of transcription and response to endogenous stimulation were the top two scoring pathways. Altered expression of cardiac genes was blunted by pretreatment with a β1-adrenoceptor blocker or α1 + β1-adrenoceptor blockers. In contrast, that of aortic genes was blunted by pretreatment with an α1-adrenoceptor blocker or α1 + β1-adrenoceptor blockers. Activation of α1-adrenoceptor in the blood vessels or activation of β1-adrenoceptors in the heart were mainly responsible for emotional stress-induced alteration of cardiac and vascular gene profiles.

Novel algorithm for identifying T-wave current density alternans using synthesized 187-channel vector-projected body surface mapping

The noninvasive evaluation of ventricular T-wave alternans (TWA) in patients with lethal ventricular arrhythmias is an important issue. In this study, we propose a novel algorithm to identify T-wave current density alternans (TWCA) using synthesized 187-channel vector-projected body surface mapping (187-ch SAVP-ECG). We recorded 10 min of 187-ch SAVP-ECG using a Mason-Likar lead system in the supine position. A recovery time (RT) dispersion map was obtained by averaging the 187-ch SAVP-ECG. The TWCA value was determined from the relative changes in the averaged current density in the T-wave zone (Tpeak ± 50 ms) for two T-wave types. We registered 20 ECG recordings from normal controls and 11 ECG recordings from nine subjects with long QT syndrome (LQT). We divided LQT syndrome subjects into two groups: group 1 provided 9 ECG recordings without visually apparent TWAs, and group 2 provided 2 ECG recordings with visually apparent TWAs. The QTc interval values in the LQT groups were higher than those in the control (515 ± 60 ms in LQT G-1, 600 ± 27 ms in LQT G-2 vs. 415 ± 19 ms in control, P < 0.001). The RTendc dispersion values among the LQT subjects were higher than those of the control subjects (48 ± 19 ms in LQT G-1, 65 ± 30 ms in LQT G-2 vs. 24 ± 10 ms in control, P < 0.01). The mean TWCA value was significantly higher in the LQT G-2 group with visually apparent TWCAs (0.5 ± 0.2% in control, 2.1 ± 1.2% in LQT G-1, and 32.3 ± 6.9% in LQT G-2). Interestingly, the two-dimensional distribution of TWCA in LQT was inhomogeneous and correlated with the distribution of increased RT dispersion. We conclude that a novel algorithm using 187-ch SAVP-ECG might provide new insights into body surface TWCA.

Stress cardiomyopathy

Recently, an increasing number of cases of stress cardiomyopathy, mainly occurring in elderly women, have been documented in many parts of the world. In Japan, this disease is known as takotsubo cardiomyopathy (named after the fishing pot used for trapping octopus). Symptoms of this condition are akin to those of acute myocardial infarction, but no obstructive lesions are found in the coronary arteries, and left ventricular apical ballooning is present. Stress cardiomyopathy is now a well-recognized cause of acute heart failure, lethal ventricular arrhythmias, and ventricular rupture. Although the precise mechanism of onset of this condition is still controversial, two major pathogenic mechanisms have been proposed: catecholamine cardiotoxicity and neurogenic stunned myocardium. We summarize the findings of studies conducted to date on stress cardiomyopathy-from bench to bedside and bedside to bench.