Usefulness of ECG to differentiate Takotsubo cardiomyopathy from acute coronary syndrome
Introduction
Takotsubo cardiomyopathy (TC) (also known as apical ballooning syndrome) is characterised by acute but rapidly reversible left ventricular (LV) dysfunction in the absence of obstructive coronary disease [1], [2]. At presentation TC typically mimic an acute myocardial infarction (AMI) and the initial electrocardiogram (ECG) exhibits ST-segment elevation in about a third of patients [3], [4], [5]. Because the in-hospital management of TC and AMI, both with and without ST-segment elevation is distinct, it would be useful to identify ECG features which facilitate the distinction between TC with and without ST-segment elevation, and ST-elevation myocardial infarction (STEMI) and non-ST-elevation MI (NSTEMI), respectively. Several ECG features of TC have been reported which may help to make these distinctions. These include absence of reciprocal changes, absence of abnormal Q-waves, absence of ST-segment elevation in lead V1, progressive QTc interval prolongation and widespread T-wave inversion [6], [7], [8].
Our aim was to examine the serial ECG patterns in TC patients, compare them with both STEMI and NSTEMI patients to identify the ECG features that may distinguish between these diagnoses, and evaluate their discriminative value both at admission and on Day 1 or 2 after admission.
Section snippets
Study population
The study population was prospectively identified from 3 coronary care units in the public hospitals in Auckland region (Middlemore Hospital, Auckland City Hospital and North Shore Hospital) between March 2004 and July 2010. One hundred consecutive patients who fulfilled the TC diagnostic criteria proposed by the Mayo Clinic group[9] and 100 patients presented with AMI (as described in the Third University Definition of Myocardial Infarction)[10] were identified. ECGs on admission, Day 1 and
Clinical characteristics
Table 1 summarises the clinical characteristics of the study population. TC patients were older (65 ± 11 years vs. 56 ± 7 years, P < 0.05) and there were more women in the TC group (95% vs. 25%, P < 0.05). TC patients with and without ST-segment elevation had similar risk factor distribution.
STE-TC versus STEMI
ECG findings of STE-TC and STEMI patients are presented in Table 2 and Fig. 1.
Discussion
To our knowledge, this study is the largest cohort published to date in Australasia and one of the largest cohorts internationally, evaluating ECG differences between TC and MI patients. The evolution of ECG changes in TC presenting with and without ST-segment elevation was similar suggesting a common underlying pathophysiology. Although at admission there were differences in the degree of ST change and incidence of Q-waves between MI and TC there was considerable overlap which limits the value
Clinical implications
It is unlikely that any ECG criteria will allow reliable discrimination of TC from MI at admission. However, in the appropriate clinical context (e.g. women who have experienced a recent emotional or physical stressor), either the presence of widespread and deep TWI in the absence of ST changes, or low grade ST segment elevation without Q-waves should raise the possibility of TC. However, given the clinical impact of delaying revascularisation in STEMI, our data do not support the ability of
Conclusion
Given the consequences of missing the diagnosis of a STEMI the diagnostic accuracy of ECG criteria were insufficient to reliably distinguish patients with TC from patients with STEMI at admission. In contrast, the differences were more marked after admission, with the absence of Q-waves being strongly suggestive of TC in those presenting with ST-segment elevation, and the late evolution of widespread and deep TWI being highly suggestive of TC in those without admission ST-segment elevation.
Conflict of interest
None.
Acknowledgement
None.
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Cited by (31)
External Validation of a Clinical Score to Differentiate Takotsubo Syndrome From Non-ST-Elevation Myocardial Infarction in Women
2023, Heart Lung and CirculationTemporal electrocardiographic changes in anterior ST elevation myocardial infarction versus the Takotsubo syndrome
2023, IJC Heart and VasculatureECG criteria to distinguish hypertrophic cardiomyopathy featured with “Pseudo-STEMI” from acute ST-elevation myocardial infarction
2023, Journal of ElectrocardiologyCitation Excerpt :The degree of ST-segment deviation was measured at the J point. The following ECG values in 12 leads were recorded manually: (1) Number of leads with STE except aVR; (2) Sum of STE; (3)Maximal STE; (4)Convex pattern of STE; (5)Presence of ST-segment depression(STD), which was defined as horizontal or down-sloping STD ≥ 0.1 mV in any lead except aVR; (6) Distribution of STD; (7)Reciprocal changes was defined as STD ≥ 0.1 mV presented at least 2 inferior leads in acute anterior STEMI, or at least 2 anterior leads in inferior STEMI [8]; (8) TWI was referred to depth ≥ −0.1 mV in any lead; (9)LVH was defined by Sokolow-Lyon criterion [9]; (10)Number of leads with TWI; (11)Distribution of TWI; (12)Abnormal Q wave was defined as Q wave≥0.03 ms, and/or 1/4 R except lead aVR, or/and QS complex in leads V2-V3; (13)Heart rate; (14)Ventricular activation time (VAT) was defined as the time from the beginning of QRS wave to the peak of R wave in precordial leads V5 or V6 [10]; (15) QRS duration was defined as the duration of the widest QRS complex in precordial leads; (16) QTc was corrected by Bazetts formula; (17) Fragmented QRS (fQRS) was characterized by the presence of a notch in the R or S wave in at least 2 consecutive leads [11]. STD/STE/TWI in -aVR(STD/STE/TWI-aVR) was defined as STE/STD/ positive T wave in aVR.
Arrhythmias and Their Electrophysiological Mechanisms in Takotsubo Syndrome: A Narrative Review
2022, Heart Lung and CirculationECG differences and ECG predictors in patients presenting with ST segment elevation due to myocardial infarction versus takotsubo syndrome
2022, IJC Heart and VasculatureCitation Excerpt :Most previous studies comparing ECG in TS versus STEMI have been based on mixed populations of TS with and without ST elevation [13–21], and/or mixed populations of STEMI or non-STEMI [13,15,22,23]. The previous studies investigating ECG in TS with ST elevation specifically versus STEMI did not match their cohorts by sex and did not discriminate between both anterior and non-anterior STEMI [24–27]. Therefore, our study could provide a more clinically representative picture of the typical admission ECG pattern in STE-TS in relation to STEMI.
Electrocardiographic changes in Takotsubo cardiomyopathy
2021, Journal of ElectrocardiologyCitation Excerpt :See Table 2.) Takotsubo Cardiomyopathy may present with or without ST elevation [23,24]. Given its resemblance in clinical signs and symptoms to the acute coronary syndrome, electrocardiographic features may aid to differentiate these two conditions [25].
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The authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.