Slide 1: 71 year-old admitted with sepsis experienced acute onset chest pain, dyspnea, and palpitations. What are the major abnormalities?

Slide 2: Inferolateral ST elevations. Also notice that the underlying rhythm is atrial fibrillation.

Slide 3: Due to the ST elevations, the patient was taken emergently to the cath lab where angiography revealed angiographically normal coronary arteries.

Slide 4: The following day, a second EKG was obtained. Given these T-wave changes, what is your differential diagnosis?

Slide 5: With deep T waves in V4-V6, 3 things come to mind: 1. Takotsubo cardiomyopathy. 2. Apical variant of hypertrophic cardiomyopathy. 3. Ischemia. Based on the EKG findings, and considering the angiography findings, what is the most likely diagnosis?

Slide 6: Progression of EKG findings can clue us in on Takotsubo cardiomyopathy. 1. ST elevations on initial presentation. Unlikely to see reciprocal changes. Typically persist for 1-3 days then subside. 2. Deep T-wave inversions with QT prolongation. T-wave inversions typically appear when ST elevations subside. 3. Normalization of EKG. 4. Also need a cath to rule out ischemia.

Slide 7: The EKG is helpful, but you need more to make the diagnosis. Revised Mayo Clinic criteria for diagnosis. 1. Transient wall motion abnormalities extending beyond a single coronary vascular distribution. Classic variant = apical ballooning and akinesis. 2. Absence of obstructive coronary disease or plaque rupture. 3. New EKG abnormalities or modest troponin elevation. $. Absence of pheochromocytoma and myocarditis.