You are called in to see a 71 year old female admitted with sepsis who is now complaining of chest pain and shortness of breath. Let’s take a look at her EKG and try to read it like a cardiologist. What are some of the most notable features here?

First, note that there are no P waves and it’s an irregularly irregular rhythm. This patient is an afib. Then, notice the ST elevations across multiple coronary distributions, including the lateral leads I and AVL. As well as the precordial leads V2 through V5. This patient needs to be taken to the cath lab emergently for concern of STEMI.

Surprisingly, there were no obstructive lesions found on coronary angio. The next day the patient’s chest pain had resolved, but her EKG is showing some new changes. Can you spot them here?

Yep, you got it! Let’s zoom into leads V4 through V6. There are now deep T wave inversions there. What’s on your differential? Given the initial ST changes followed by the deep T wave inversions, we should be thinking about Takotsubo cardiomyopathy, apical variant hypertrophic cardiomyopathy, and myocardial ischemia. A transthoracic echo is ordered. What do you expect to see?

So, in this apical two chamber view of the echo, we see a ballooning hypokinetic left ventricular apex, as well as a narrow hyperkinetic left ventricular basal segment, all features consistent with Takotsubo or stress induced cardiomyopathy.

So, what are the takeaways today? Well, Takotsubo cardiomyopathy can result in transient dilation and hypokinesis of the left ventricular apex that’s associated with severe physical or emotional stress. Who is Takotsubo most common in? That’ll be our older female patients. Takotsubo’s clinical presentation can often mimic those of STEMIs, with ST changes followed by deep T wave inversions. And troponins can also be elevated in Takotsubo, though its degree of elevation may be disproportionately low compared to the amount of wall motion abnormalities often seen on echo. And ultimately, angiography may be needed to differentiate between Takotsubo and acute coronary syndromes.

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Takotsubo Cardiomyopathy

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