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Sheneef Sunderji, Vignendra Ariyarajah, Viktor Solodun, Nasir Shaikh and James W Tam
American Heart Journal Volume 7 No.2

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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.

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Tako-Tsubo cardiomyopathy (TTC), also known as transient left ventricular apical ballooning syndrome,¹ is a reversible, stress-induced cardiomyopathy that predominantly affects post-menopausal, elderly women during emotional or physical stress.^1,2 Although it is an increasingly recognized and reported syndrome, the syndrome remains uncommon, occurring in < 1% of patients referred for coronary angiogram.

Because the electrocardiogram (ECG) classically depicts ST-segment elevations and cardiac biomarkers can often be raised, it can be a challenge to differentiate TTC from an acute myocardial infarction (AMI). Therefore, TTC generally remains a diagnosis per exclusionem, i.e. a diagnosis of exclusion, where an acute coronary syndrome usually needs to be ruled out. Ogura et al.,³ however, proposed specific ECG criteria to aid in the diagnosis of TTC (see Table 1). They suggested that the absence of reciprocal changes, absence of abnormal Qwaves, and a ratio of ST-segment elevation in leads V(4-6)/V(1-3) ≥1 all showed a high sensitivity and specificity for diagnosing TTC versus anterior AMI. In addition, they demonstrated that the combination of the absence of reciprocal changes and the ratio of STsegment elevation in leads V(4-6)/V(1-3) ≥1 on a standard 12-lead ECG had a greater specificity (100%) and overall accuracy (91%) than either criterion (see Table 1). We present a case series where, although such ECG criteria had been specifically employed, TTC remained a diagnosis of exclusion, necessitating coronary artery catheterization to rule out myocardial infarction.

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