A 73-year-old woman, with a history of hypertension and high cholesterol, was admitted to the hospital because of chest discomfort, which she had never experienced before. She did not have any stressful event recently. Troponin levels were elevated. She was treated for acute coronary syndrome and was given medication accordingly.
The ECG showed elevated ST segments in V3 and negative T waves in V3-V6. Obstructive coronary artery disease was ruled out with a cardiac catheterization. The echocardiogram showed hyperkinetic basal segments and an akinetic apex.
A MRI examination of the heart was performed 6 days later: the two- and four-chamber recordings showed preserved regional wall motion of the left ventricle anterior and inferior at the base but the apex was completely akinetic, with apical ballooning (Fig. 1, 2 and Fig. 4, 5 cine). The LVEF was calculated at 54%. The left ventricle had normal dimensions. The right ventricle was normal. There was a normal tricuspid aortic valve. There was no delayed enhancement (Fig. 3) or perfusion defect during stress or rest.
Four months later a cardiac MRI was repeated on which there was a complete normalisation of the left ventricle contraction pattern. The LVEF was 74% (Fig. 4, 5).
A. Takotsubo cardiomyopathy (TCM) is a transient cardiac syndrome that involves left ventricular apical akinesis and mimics acute coronary syndrome. The pathophysiology is not fully understood, the syndrome appears to be triggered by a significant emotional or physical stressor [1, 3].
B. Patients usually present with acute chest pain with high levels of troponin suggestive of myocardial infarction. A cardiac catheterization or coronary CTA is needed to exclude an acute occlusion of a coronary artery in the case of myocardial infarction . To differentiate between takotsubo and myocardial infarction echocardiography and/or MRI is needed. A MRI is often superior to echocardiography because MRI has the ability to differentiate between myocardial infarction and takotsubo with the use of delayed enhancement and MRI usually has better visualisation of the apex.
C. The Japanese word takotsubo translates to "octopus pot", resembling the shape of the left ventricle during systole on imaging studies . This shaped can be seen on MRI, ultrasound of the heart and during angiography of the left ventricle. The apex is akinetic. There should be no delayed enhancement and no perfusion defects during stress. The main element is that the cardiomyopathy is reversible. A sequential MRI should show a normalisation of the left ventricular contraction pattern. T2 weighed imaging could be used to demonstrate myocardial oedema initially.
D. There is no specific treatment. Beta-blockers seem to be useful. In-hospital mortality is presumed to be approximately 2% . The prognosis on the long term, if the patient has survived the acute period, is excellent. One of the complications is thrombus formation in the apex of the left ventricle. Close follow-up care by a cardiologist and imaging in the weeks after the diagnosis is recommended for patients with TCM to ensure resolution of the cardiomyopathy .
E. In a patient with acute chest pain and a history of stress, takotsubo cardiomyopathy should always be in the differential diagnosis. The hallmark of takotsubo cardiomyopathy is apical ballooning with an akinetic apex and no delayed enhancement or perfusion defects. Obstructive coronary artery disease must be excluded. Takotsubo cardiomyopathy is reversible and should resolve completely.
Differential Diagnosis List