Question of the week


Your ESCardioEd challenge by Dr Umberto Barbero and team, Santissima Annunziata Hospital of Savigliano, ASLCN1, Savigliano, Italy.

After two days from an episode of acute pain in the left shoulder, which radiated posteriorly and lasted one hour then slowly vanished, a 74 years-old lady reported the episode to her General Practioner who asked for an ECG (figure below). She was referred to the emergency department where echocardiography showed severe impairment of left ventricular function with mid-apical akinesia and hyperkinetic basal segments, with a giant thrombus in the apex (video in the comments section). She was taken in our Intensive Cardiac Unit and she was treated with diuretics, heparin, aspirin, beta-blockers and ticagrelor and prepared for coronary angiography.

What"s the diagnosis?
1. Late anterior STEMI presentation, by then asymptomatic
2. Brugada Syndrome
3. Takotsubo syndrome
4. Dilated Cardiomyopathy with embolizing left ventricular apical thrombus


Answer:

Correct answer is Takotsubo.

The ECG evolved with an ischemic pattern in the next days (figure 1), but the coronary angiography showed normal coronary arteries (video in comments section). As part of a MINOCA work-up the patient received cardiac magnetic resonance: T2-weighted sequences which identified the presence of oedema of the apical and mid-segments, without any sign of late gadolinium enhancement, consistent with the diagnosis of Takotsubo syndrome (figure 2). After 3 months, follow-up echocardiography revealed the complete recovery of ventricular function with the disappearance of the apical thrombus and of pericardial effusion.
 While every option mentioned could be advocated as potentially true, CMR was the key diagnostic algorithm with the evidence of a typical Takotsubo pattern. The ECG findings in Takotsubo cardiomyopathy ― also known as stress-induced cardiomyopathy, broken-heart syndrome or apical-ballooning syndrome ― are nonspecific, meaning there is no typical ECG appearance to diagnose this disease state.

(figure 1)

(figure 2)