Coronary artery disease
Spectrum and Significance of Electrocardiographic Patterns, Troponin Levels, and Thrombolysis in Myocardial Infarction Frame Count in Patients With Stress (Tako-tsubo) Cardiomyopathy and Comparison to Those in Patients With ST-Elevation Anterior Wall Myocardial Infarction

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Stress (takotsubo) cardiomyopathy (SC) is a recently recognized syndrome with clinical and electrocardiographic (ECG) presentation resembling ST elevation anterior myocardial infarction. As experience with this condition has evolved, a more diverse spectrum of 12-lead ECG patterns has emerged that may affect differential diagnosis. Fifty-nine consecutive patients with SC were prospectively identified at a large community-based cardiology practice. All were women aged 32 to 90 years (mean 66 ± 13) with acute chest pain triggered by emotional or physical incidents and with akinesia of the mid-distal left ventricle; each patient recovered and was discharged within a median of 4 days. On electrocardiography, anterior ST elevation was most common (33 [56%]), with magnitudes less than in controls with left anterior descending coronary artery occlusions (1.4 ± 1.5 vs 2.4 ± 2.2 mm, p <0.001), with considerable overlap. ECG findings in 26 other patients (44%) without ST elevation revealed diffuse T-wave inversion (10 [17%]) and healed anterior infarctions (6 [10%]) or were nonspecific (5 [8.5%]) or normal (5 [8.5%]). Troponin elevations occurred in 56 patients with SC (95%). The mean peak troponin T level was significantly lower in patients with SC (0.64 ± 0.86 ng/ml) than in those with left anterior descending coronary artery occlusions (3.88 ± 4.9 ng/ml) (p <0.0001). Patients with SC with or without ST elevation did not differ with respect to the ejection fraction (29 ± 9% vs 34 ± 9%, respectively, p = NS) or Thrombolysis In Myocardial Infarction (TIMI) frame counts. During recovery, diffuse T-wave inversion evolved in 49 patients with SC (83%). In conclusion, patients with SC present with diverse ECG findings, and no single pattern alone can reliably distinguish this condition from acute coronary syndromes. The diagnosis of SC requires heightened awareness of its unique clinical profile as well as coronary arteriography and left ventriculography.

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Methods

From August 2001 to April 2006, 59 consecutive patients with SC presented to the Minneapolis Heart Institute at Abbott Northwestern Hospital. All patients were women, ranging in age from 32 to 90 years (mean 66 ± 13). These patients demonstrated the following features: (1) an acute cardiac event typically presenting with substernal chest discomfort, (2) systolic dysfunction with akinesia or hypokinesia of the mid and distal left ventricular (LV) chamber associated with a hypercontractile basal

Results

The distribution of initial ECG diagnostic patterns was as follows: ST elevation, most common in leads V2 and V3 (n = 33 [56%]); widespread T-wave inversion (n = 10 [17%]); healed anterior infarctions (n = 6 [10%]); nonspecific (n = 5 [8.5%]); and normal (n = 5 [8.5%]) (Figure 1, Figure 2). Patients with or without ST elevation did not differ with regard to the ejection fraction (29 ± 9% vs 34 ± 9%, respectively) or the presence of apical sparing (9 of 33 [27%] vs 10 of 26 [38%], respectively).

Discussion

Previously, we1 and others5, 8, 9, 10, 14 have underscored the importance of differentiating SC from the much more common acute anterior wall myocardial infarction, particularly because it has been emphasized that the 2 conditions may present with ST-segment elevation pattern on initial electrocardiography. However, previous reports are conflicting with respect to the frequency of ST elevation reported in this condition. In a number of reports from Japan2, 5, 10 and elsewhere,7, 8, 15, 16, 17

Acknowledgment

We acknowledge Dr. Morrison Hodges for his helpful insights.

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    This study was supported in part by the Minneapolis Heart Institute Foundation, Minneapolis, Minnesota; the National Heart Foundation of New Zealand, Auckland, New Zealand; and the Waikato Heart Trust, Hamilton, New Zealand.

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