Performance of a novel clinic score in differentiating Takotsubo cardiomyopathy from ST elevation myocardial infarction within the first 24h

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.

[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.

Discrimination of stress (Takotsubo) cardiomyopathy from acute coronary syndrome with clinical risk factors and coronary evaluation in real-world clinical practice

BACKGROUND

Diagnosing stress cardiomyopathy (SCMP) apart from acute coronary syndrome (ACS) is challenging since coronary evaluation is not always feasible in real-world clinical practice. We explored the current practice pattern of coronary evaluation in patients suspected to have SCMP and divulged the distinguishable features of SCMP from ACS.

METHODS AND RESULTS

From 2010 to 2015, only 219 out of 691 (32%) hospitalized patients suspected to have SCMP have received coronary evaluation in two tertiary hospitals. After the evaluation, 66 patients (30%) turned out to have ACS. Coronary evaluation was performed based on coronary risk factors, clinical presentations, and test results including electrocardiograms (ECG), cardiac biomarkers, and echocardiography. Whereas initial presentations, ECG changes, cardiac biomarkers, and regional wall motion abnormality patterns were not significantly different, multivariate logistic regression analysis showed that age (≥70years), diabetes, a history of percutaneous coronary intervention (PCI), and the absence of evident triggers were significant factors discriminating ACS from SCMP. A decision tree based on classification and regression analysis also revealed the consistent results.

CONCLUSIONS

Although it is hard to differentiate SCMP from ACS merely based on clinical features, a substantial proportion of patients suspected to have SCMP did not undergo coronary evaluation to exclude ACS in real-world clinical practice. Coronary evaluation should be more actively performed in patients with old age, prior PCI history, diabetes, and less evident trigger.