A 45-year-old lady presented to the AED with SOB and chest discomfort. She enjoyed good past health, including a normal CT coronary angiogram (CTCA) performed a few months ago.
Which of the following stagement is correct?
Choose the correct answer.
Index ECG showed ST segment elevation involving V2-6, compatible with Anterior STEMI. A recent normal CTCA cannot rule out non-plaque-related coronary obstructions, such as spontaneous coronary artery dissection (SCAD) or thrombotic occlusion.
However, the absence of reciprocal changes in Leads III and aVF, together with PR-segment depression in Leads II, V5, and V6, is not a typical finding of an anterior STEMI. Although anterior STEMI remains the provisional ECG diagnosis, alternative uncommon differentials should be considered, such as Takotsubo cardiomyopathy or concurrent peri-infarction pericarditis (PIP) masking reciprocal changes.
A bedside echocardiogram is highly valuable in this scenario. The absence of akinetic segments in the LAD distribution, together with apical ballooning and hypercontractile basal segments, is suggestive of Takotsubo cardiomyopathy.
However, a coronary angiogram remains mandatory, as Takotsubo cardiomyopathy is a diagnosis of exclusion.
The coronary angiogram was normal. Left ventriculography (LV-gram) showed typical apical ballooning with preserved basal contractions. Cardiac MRI can provide markers for reversible injury (inflammation, ischemic edema) and irreversible damage (necrosis/fibrosis). This is particularly important for verifying the diagnosis of Takotsubo cardiomyopathy and excluding similar acute cardiac diseases, such as myocarditis.
The final diagnosis was Takotsubo cardiomyopathy.
A follow-up ECG was performed a few days later, which showed resolution of the ST elevation along with new, diffuse T-wave inversions. This ECG finding suggests a global repolarization abnormality, commonly seen following diffuse myocardial injury.
Further information regarding Takotsubo cardiomyopathy cound be found in
