Electrocardiographic criteria in tako-tsubo cardiomyopathy-is there added certainty in a diagnosis per exclusionem?

Abstract

Tako-Tsubo cardiomypathy (TTC), also known as transient left ventricular apical ballooning syndrome, is a stress-induced cardiomyopathy that predominantly affects post-menopausal, elderly women during emotional or physical stress. Apical left ventricular dysfunction in the absence of significant coronary artery disease is the hallmark of this condition. Because the electrocardiogram (ECG) classically depicts precordial ST-segment elevations and cardiac biomarkers can often be raised, it can be a challenge to differentiate TTC from an acute myocardial infarction (AMI). Indeed, several recent studies have proposed ECG criteria to differentiate TTC from an AMI. We present a case series of consecutive patients in whom we had employed such ECG criteria but were unable to conclusively differentiate TTC from an AMI. In each case, TTC remained a diagnosis per exclusionem, where coronary angiography was necessary to rule out myocardial infarction. We review and discuss the commonly used ECG criteria and highlight the evolutionary ECG changes commonly noted with TTC to help better prepare clinicians when dealing with patients with similar clinical scenarios.