Midventricular Takotsubo syndrome mimicking a thrombolysed anterior ST-elevation myocardial infarction

A 62-year-old woman, current smoker, without other cardiovascular risk factors, presented in a satellite district hospital with typical chest pain lasting 2–3 h and vomiting. The electrocardiography (ECG) at presentation showed ST segment elevation in precordial leads V1-V3; therefore, the patient was thrombolysed with tenecteplase. Post-thrombolysis, the patient was haemodynamically and clinically stable on dual antiplatelet therapy (aspirin and clopidogrel). A bedside transthoracic echocardiogram showed moderate left ventricular systolic dysfunction (LVEF: 40%) and that cardiac troponin T was elevated to 1000 pg/ml (normal value < 14 pg/ml). The patient was subsequently transferred to our centre for a coronary angiogram ± percutaneous coronary intervention (PCI). The coronary angiogram performed via the left transradial approach and showed unobstructed coronary arteries. Left anterior descending and left circumflex arteries had separate ostia (Figures 1 A–C). Left ventriculography demonstrated moderate left ventricular systolic dysfunction with akinesia of the midventricular myocardial segments and preserved systolic function of the basal and apical segments, an angiographic appearance compatible with midventricular Takotsubo syndrome (Figures 1 D–F). Taking a thorough patient history in the cath lab, we found that the symptoms had started after a major dispute with a first-degree family member, which perfectly fitted our diagnosis. The patient was discharged 2 days later on a -blocker and an angiotensine convertase enzyme (ACE) inhibitor and was scheduled for cardiac magnetic resonance (CMR) imaging at 1 month post discharge. The CMR showed complete recovery of left ventricular systolic function.
Takotsubo syndrome (TTS), formerly known as Takotsubo cardiomyopathy, stress-induced cardiomyopathy, broken heart syndrome, and transient apical ballooning, was first described in Japan in 1990 and refers to an acute reversible heart failure syndrome that is characterized by transient LV regional wall motion abnormalities usually extending beyond a single epicardial vascular distribution, in the absence of obstructive coronary artery disease or plaque rapture in coronary angiography [1, 2]. TTS patients present with chest pain, ECG changes (ST-segment elevation, ST depression, or T-wave inversion) and troponin elevation. Overall, 1% to 2% of patients with suspected acute coronary syndrome (ACS) and 5% to 6% of all women presenting with suspected...


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