Documentation of dynamic electrocardiographic changes shortly after the onset of tako-tsubo cardiomyopathy

A 76-year-old female with atrial fibrillation and prior cerebral infarction had chest discomfort during rehabilitation for left hemiparesis, and visited the nearby hospital. Her ECG, which was obtained 10 min after the onset, showed marked ST-segment elevation in leads I, II, III, aV(F) and V(2-6), and she was referred to our hospital for cardiac examination. On admission, her ECG, which was obtained 50 min after the onset, showed poor R wave progression and mild ST-segment elevation in leads V(5-6). During only 10 min after the admission, the ST-segment level increased dynamically, and it decreased spontaneously again. Left ventriculography showed akinesia of the mid-to-distal portion and hyperkinesia of the basal portion of the left ventricular chamber, and coronary angiography showed no significant coronary artery disease despite of significant ST-segment elevation. We diagnosed her as having tako-tsubo cardiomyopathy. She was discharged well 10 days later.     

Tako-tsubo cardiomyopathy after automobile accident

A 53-year-old woman was involved in a traffic accident while driving her car. She had chest oppressive sensation 6 h after the accident, and was admitted to our hospital. On admission, she had no external injury. She was fully conscious, and felt anxiety about the accident. Twelve-lead electrocardiogram showed mild ST-segment elevation in leads II, III, aVF and V2-5. Chest X-ray did not show pneumothorax, rib fracture or pulmonary congestion. Emergency coronary angiography showed no significant coronary artery disease. However, left ventriculography showed akinesia of the mid-to-distal portion of the left ventricular chamber and hyperkinesia of the basal portion (ejection fraction=45%). She was diagnosed as having tako-tsubo cardiomyopathy. Follow-up left ventriculography 11 days later showed normal wall motion of the left ventricular chamber (ejection fraction=62%). Clinicians should recognize that tako-tsubo cardiomyopathy is one of etiologies of chest symptom after automobile accident. It can occur due to emotional stress even if patients have no external injury.     

Repeated changes of electrocardiogram caused by Takotsubo-type cardiomyopathy: a case with hypertrophic nonobstructive cardiomyopathy

A 67-year-old woman had been examined due to abnormalities on electrocardiography (ECG) at a medical checkup three years previously. When a negative T-wave was seen in leads I, aVL, and V1 to V4, but the abnormal findings were improved at consultation. Echocardiography revealed apical hypertrophy and hypertrophic nonobstructive cardiomyopathy was diagnosed. She felt chest discomfort in September, 2003 and an ECG showed a negative T-wave in leads I, II, III aVL, aVF and V2 to V6 and an elongation of QT interval Left ventriculography revealed myocardial hypertrophy at the left ventricular apex and left ventriclar wall motion was normal. Coronary angiography did not show any significant luminal narrowing. I-123 metaiodobenzyl-guanitidine scintigraphy showed marked perfusion defects at the left ventricular apex. After five months, ECG showed an improvement of the QT interval and a decrease in the negative T-wave. We considered that the repeated changes of ECG were caused by Takotsubo-type cardiomyopathy.     

Ampulla cardiomyopathy with left ventricular apical mural thrombi resolved by anticoagulant therapy without systemic complication: a case report

A 79-year-old woman was admitted for treatment of bronchial asthma. ST-segment elevation in the precordial leads (V4-V6) and T-wave inversion in leads II, III, and aVF was recognized. Transthoracic echocardiography and emergent cardiac catheterization demonstrated two large mobile thrombi (1.2 x 1.3 cm, 0.7 x 1.0 cm) attached to the left ventricular wall. There was no organic stenosis. Left ventriculography revealed anterolateral, apical and inferior dyskinesis, and basal hyperkinesis. The clinical diagnosis was ampulla cardiomyopathy. Anticoagulant therapy was started. Prothrombin time-international normalized ratio was remained at 2.5-3 and partial thromboplastin time was controlled at 1.5-2 times compared with the normal value. Repeated echocardiography showed the mass reduced gradually and had disappeared about 2 weeks later.     

Subarachnoid hemorrhage complicated with different manifestations of transient abnormal left ventricular wall motion: two case reports

Two patients with subarachnoid hemorrhage presented with transient abnormal left ventricular wall motion. Case 1 was a 56-year-old man. Electrocardiography showed ST segment elevation in leads I, II, II, aVL, aVF, V3-V6. Echocardiography showed localized left ventricular hypokinesis around the apical area (takotsubo-like cardiomyopathy). Ejection fraction was 20% (1st hospital day). Troponin T was positive. Case 2 was a 48-year-old woman. Electrocardiography showed ST segment elevation in leads I, aVL, V2-V6 and ST segment depression in leads II, III, aVF, V1. Echocardiography showed diffuse left ventricular hypokinesis. Ejection fraction was 21% (1st hospital day). Troponin T was positive. These two patients had no history of cardiac disease, and coronary angiography showed no stenosis or obstruction. Catecholamine was given for 1 day(Case 1) and for about 2 weeks (Case 2). Pimobendane was given to Case 2. Ejection fraction was 57% in Case 1 (2nd hospital day) and 33% (6th hospital day), 43% (7th hospital day)and 58% (16th hospital day)in Case 2. The recovery period of left ventricular abnormal wall motion and the medication period were longer in Case 2 showing diffuse hypokinesis than in Case 1 showing takotsubo-like cardiomyopathy.     

Reversible left ventricular apical ballooning associated with jet lag in a Taiwanese woman: A case report

Reversible left ventricular apical ballooning, without coronary artery stenosis, is a novel heart syndrome mimicking acute myocardial infarction, and is very rare in Taiwan. A 74-year-old Taiwanese woman returned from travelling abroad for one week and suffered from persistent, severe jet lag with sleep disturbance. She had a cold exacerbated by bronchial asthma for three days. She presented with sudden onset of chest pain after drinking three cups of coffee and taking a sauna for more than 1 h. On admission, an electrocardiogram showed ST segment elevation in leads II, III, aVF and V(3-6), and cardiac enzyme tests revealed minimal elevation. An echocardiogram showed apical ballooning and basal hyperkinesias of the left ventricle (LV) in systole. A coronary angiogram on the second day was normal, while the ST segment was still elevated, and the patient continued to experience chest pain. A negative T wave developed three days later. The electrocardiogram abnormality and LV dysfunction resolved completely six months later. A takotsubo (ampulla) cardiomyopathy was diagnosed. The activated myocardial adrenergic nervous system, stimulated by acute and marked stress in this patient, with more adrenergic innervations distributed in the apex of the LV, may be the trigger for this novel cardiac syndrome.     

Marked ST-segment elevation in the precordial and inferior leads in right ventricular myocardial infarction: a case report

This is a report of right ventricular infarction complicated by inferior myocardial infarction in which marked ST-segment elevation was observed in the precordial and inferior leads. A 51-year-old man was admitted with chest pain of one-half hour duration. His admission ECG showed conspicuous ST-segment elevation in the precordial and inferior leads. The maximum magnitude of the ST-segment elevation in the precordial leads was 21 mm in lead V2 and 10 mm in lead II. Echocardiography showed akinesis of the right ventricular free wall and the posterior half of the left ventricle. Angiography revealed a 90% reduction in the diameter of the right coronary artery in its proximal portion, and a normal left coronary system. Recent reports have indicated that precordial ST-segment elevation may reflect right ventricular infarction. However, there has been no previous report of marked ST-segment elevation in the precordial and inferior leads. In right ventricular infarction, the currents of injury usually occur simultaneously in the right ventricular free wall and left ventricular inferior wall, and then are electrically opposed to each other. The diffuse and marked ST-segment elevation observed in this case is thus a rare phenomenon.     

The importance of the evolution of ST-T wave changes for differentiating acute pericarditis from myocardial ischemia

A 28-year-old, moderately obese man with dyslipidemia (low-density lipoprotein 163 mg/dL, high-density lipoprotein 33 mg/dL), hypertension, active tobacco use (1 pack per day), and a family history for premature coronary artery disease (CAD) initially presented with burning, nonexertional chest discomfort exacerbated by deep inspiration. His initial electrocardiogram (ECG; Fig. 1A) was interpreted as pericarditis because of the diffuse mild ST-segment elevation and PR-segment depression. An echocardiogram demonstrated normal left ventricular systolic function and a trivial pericardial effusion. He was treated with nonsteroidal antiinflammatories and his symptoms resolved. Follow-up ECG performed the next morning (Fig. 1B) demonstrated sinus rhythm, persistent mild ST elevation, and biphasic T waves in leads V3-V4 as well as in leads III and aVF. Four months later, the patient returned with similar symptoms of chest discomfort and was admitted with the diagnosis of unstable angina. The admission ECG was unremarkable showing no persistent PR or ST-T abnormalities. He was ruled out for myocardial infarction by serial enzymes. An exercise myocardial perfusion imaging study was obtained. The patient exercised for 7 minutes 33 seconds on a standard Bruce protocol, obtained 9.4 METs, and reached 69% of maximum predicted heart rate. His exercise ECG revealed up to 2.5 mm of ST-segment elevation in leads V3-V5 accompanied by chest discomfort. The patient's chest pain resolved with cessation of exercise and 1 sublingual nitroglycerin. The ECG returned to baseline within 3 minutes of recovery. He was referred for coronary angiography and was found to have a proximal left anterior descending (LAD) stenosis and underwent percutaneous coronary intervention with stenting. He was discharged home on postprocedure day 3.     

Tako-tsubo-like syndrome without emotional stress: a case report]

The tako-tsubo-like syndrome (also named left ventricular apical ballooning) is an unusual cardiomyopathy with a high incidence in the Japanese female population, following an emotional stress. The clinical features (typical chest pain), electrocardiographic (negative T wave and persistent ST-segment elevation in anterior leads), echocardiographic (transient left ventricular apical dysfunction with hyperkinesis of basal segments) are suggestive of an acute anterior myocardial infarction; nevertheless all reports in the literature show coronary arteries without angiographic lesions. We report the case of a 77-year-old female (without cardiovascular risk factors) with two prior episodes of paroxysmal atrial fibrillation, who arrived to the emergency department with chest pain, electrocardiographic and echocardiographic features, suggestive of an acute anterior myocardial infarction, not preceded by any emotional stress. Coronary angiography showed coronary arteries without atherosclerotic lesions; left ventriculography showed an anteroapical dysfunction. The follow-up performed with transthoracic echocardiography (2 months later) showed complete regression of regional wall motion abnormalities. The pathophysiological determinant seems to be related to the release of catecholamines (such as epinephrine and norepinephrine) able to create a transient board of ischemic cardiomyopathy through a direct cellular damage.     

Takotsubo-like transient biventricular dysfunction with pressure gradients

A 78-year-old woman was admitted to our hospital due to chest oppressive sensation. Admission electrocardiography revealed ST-segment elevation in I, II, III, aV(F) and V(2-6) leads. Left ventriculography showed apical akinesis and basal hyperkinesis with a pressure gradient of 60 mmHg between the left ventricular apex and the base. Right ventriculography also showed similar abnormal wall motion with a pressure gradient of 28 mmHg. Follow-up cardiac catheterization after 16 days showed normal wall motion with no pressure gradients. However, dobutamine stress (10 microg/kg/min) caused a pressure gradient of 60 mmHg between the left ventricular apex and the aorta.     

Tako-tsubo-like transient left ventricular dysfunction with apical thrombus formation: a case report

A 76-year-old woman with oppressive chest pain was admitted to our hospital. Initial electrocardiography revealed normal sinus rhythm with ST-segment elevation in leads V2-V5. The patient underwent emergent coronary angiography, which demonstrated no significant coronary stenosis. Left ventriculography revealed marked hypokinesis and akinesis of the mid and distal segments of all ventricular walls, with hyperkinesis of the base. Six days after admission, transthoracic echocardiography revealed immobile apical thrombus. The thrombus disappeared without any embolic episode after 2 weeks of anticoagulant therapy with heparin and warfarin. Left ventricular walls returned to normal 3 months after the attack. Tako-tsubo-like cardiomyopathy with apical thrombus has only been reported in three cases. Left ventricular function normalizes within several days or weeks in most cases of tako-tsubo-like transient left ventricular dysfunction. Therefore, if the thrombus remains within the left ventricle, the risk of embolism might be relatively high. Careful management must be required in patients with tako-tsubo-like transient left ventricular dysfunction.     

Diagnosis of acute myocardial infarction in angiographically documented occluded infarct vessel : limitations of ST-segment elevation in standard and extended ECG leads.

STUDY OBJECTIVES: The majority of thrombolysis studies require defined ST-segment elevations as an inclusion criterion for the diagnosis of acute myocardial infarction (AMI). However, depending on the occluded infarct vessel and the criteria applied, the ECG diagnosis of AMI can be difficult to establish. Accordingly, this study was performed to evaluate the sensitivity of ST-segment elevation of standard and extended ECG leads in a cohort of patients with angiographically confirmed diagnosis of AMI. PATIENTS AND METHODS: In 418 patients (mean +/- SD age, 60 +/- 13 years) with AMI (pain onset, 4.8 +/- 3.0 h), coronary angiography with percutaneous transluminal coronary angioplasty/stenting of the culprit lesion was performed. The diagnosis of AMI was confirmed by emergency coronary angiography and laboratory analyses. ST-segment elevation (in two contiguous leads) of 1 mm in standard lead I through aVF and ST-segment elevations of 2 mm (or 1 mm, corresponding values presented in parentheses) in V(1) through V(6) were considered significant. In a subset of 102 AMI patients, additional right precordial leads V(3)R through V(6)R for evaluation of right ventricular infarction and additional chest leads V(7) through V(9) for evaluation of posterior infarction were recorded. ST-segment elevations of 1 mm in the right precordial leads and 1 mm or 0.5 mm in the posterior leads were considered significant. RESULTS: Standard leads I through V(6) showed ST-segment elevation in 85% (96%) of patients with left anterior descending artery occlusion, in 46% (61%) of patients with left circumflex coronary artery (CX) occlusion, and in 85% (90%) of patients with right coronary artery occlusion. On consideration of additional ECG tracings in the subgroup of 102 patients (V(3)R through V(6)R and V(7) through V(9)), the respective numbers increased by 2 to 8% depending on different criteria for ST-segment elevation; in patients with CX occlusion, the increase amounted to 6 to 14%. There was a trend toward an extended infarct size (maximum creatine kinase [CK] values) with concomitant ST-segment elevation in additional ECG leads as assessed by maximum CK levels. CONCLUSIONS: The sensitivity of the ECG diagnosis of AMI is only marginally increased by extended precordial chest leads. There is a trend toward an extended infarct size in those patients with concomitant ST-segment elevation in additional ECG leads.     

Variant form of tako-tsubo cardiomyopathy

We report a female case of variant form of tako-tsubo cardiomyopathy in which wall motion of the distal segment was preserved. In the current case, left ventriculography showed akinesia of the mid portion and normokinesia of the distal and basal portions of the left ventricular chamber. ST-segment elevation was obvious in leads V1-3 rather than in leads V4-6. Because ST-segment elevation is absent in left precordial leads, cardiologists should take care not to fail to diagnose variant form of tako-tsubo cardiomyopathy.     

Takotsubo cardiomyopathy presenting as multivessel coronary spasm syndrome: case report and review of the literature

Takotsubo' cardiomyopathy, more recently called transient left ventricular apical ballooning syndrome, is a recently described acute cardiac syndrome. This increasingly reported syndrome consists of an acute onset of transient extensive akinesia of the apical and mid-portions of the left ventricle, producing ballooning of the apex in systole in the absence of significant coronary artery disease. The syndrome is accompanied by angina-like chest pain, electrocardiographic changes and minimal release of cardiac enzymes and biomarker levels, mimicking an acute myocardial infarction and is often preceded by an episode of emotional or physical stress, which may play a key role in the pathogenesis of the disorder. However, the exact mechanism still remains unknown. We describe the history of an 83-year-old man presenting to the emergency department with clinical findings of acute myocardial infarction with ST-segment elevation in the precordial leads, but emergency coronarography showed no significant obstruction. Left ventricular angiography demonstrated the typical apical ballooning. ST-segment elevation in the precordial leads on the admission ECG resolved the day after, but new anginal chest pain was accompanied by transient ST-segment elevation in the inferior leads, suggesting multivessel coronary spasm. Awareness of the existence of the syndrome is important and should be considered in the differential diagnosis of patients presenting with an acute coronary syndrome.     

Exercise-triggered transient R-wave enhancement and ST-segment elevation in II, III, and aVF ECG leads: a testament to the "plasticity" of the QRS complex during ischemia

We describe a patient with coronary artery disease who showed transiently augmented R-waves in his electrocardiogram (ECG) during the course of an exercise treadmill test (ETT), an ECG pattern occasionally associated with the hyperacute phase of myocardial infarction and variant angina. This change in the R-waves was noted in II, III, and aVF ECG leads and was associated with ST-segment elevation; both changed gradually and were normalized during the recovery period. Cardiac enzymes after ETT were negative, and arteriography revealed 3-vessel coronary artery disease, with a completely occluded right coronary artery. The ventriculogram showed very mild hypokinesis of the inferior left ventricular wall, while the global ejection fraction was 75%. These ECG changes, noted previously during ETT in precordial ECG leads, are herein reported to occur also in II, III, and aVF ECG leads. The generation of these ECG changes, which hinges upon a late unopposed depolarization occurring in the course and at the site of severe ischemic injury, constitutes a transient focal ventricular conduction abnormality.     

Documentation of early improvement of left ventricular function in tako-tsubo cardiomyopathy

An 86-year-old woman was admitted to our hospital because of chest pain after a heated argument with her daughter. Electrocardiogram showed ST-segment elevation in leads V2-3 and T wave inversion in leads V3-6. Emergency cardiac catheterization was performed 2 h after the onset of chest pain. Coronary angiography showed no significant coronary artery disease. However, left ventriculography showed apical akinesis and basal hyperkinesis (ejection fraction=42%). She was diagnosed as having tako-tsubo cardiomyopathy. Follow-up left ventriculography showed marked improvement of the left ventricular function (ejection fraction=74%) during only 41 h. She was discharged 3 days later.     

Differentiation between left circumflex and right coronary artery occlusions: studies on ST-segment deviation during percutaneous transluminal coronary angioplasty

To distinguish between acute occlusion of the right coronary artery (RCA) and the left circumflex artery (LCx) by electrocardiography, we studied ST-segment deviation during balloon inflation in percutaneous transluminal angioplasty. The composite electrocardiographic criteria based on ST-segment deviations increased the diagnostic specificity: that is, the finding of inferior infarction (ST-segment elevation in leads II, III, aVF) without lateral infarction (ST-segment elevation in leads V5,6) was highly suggestive of RCA occlusion (sensitivity and specificity: 35 of 43 cases, 81.4%; and 33 of 36 cases, 91.7%), whereas ST-segment elevation in leads V5,6 (LCx: 23 of 36 cases; 63.9%, RCA: 5 of 43 cases; 11.6%) or isolated ST-segment depression in leads V2-4 (LCx: 9 of 36 cases; 25.0%, RCA: none of 43 cases) was highly suggestive of LCx occlusion. These results indicate that the composite electrocardiographic criteria were useful in predicting the artery involved in acute myocardial infarction, although any single criterion was not sensitive or specific enough to differentiate right from left circumflex coronary artery occlusion.     

A case of ST-segment elevation provoked by distended stomach conduit

A case of ST-segment elevation provoked by distended stomach conduit is presented. An 83-year-old woman was admitted to our hospital with worsening chest discomfort. She had a previous history of subtotal esophagectomy, which was reconstructed using a stomach conduit in the posterior mediastinum. Electrocardiogram showed ST-segment elevation in the inferior leads and a prominent negative P wave in lead V1. Echocardiography demonstrated normal left ventricular function without regional wall motion abnormality; however, the left atrium and ventricle compressed by a substantially distended stomach conduit was noted. Subsequent angiocardiography revealed no coronary atherosclerotic stenosis and normal contractility of the left ventricle. Chest symptoms resolved soon after nasogastric suction, leading to resolution of electrocardiographic changes. The stomach conduit diminished on following repeated echocardiography. The patient was discharged without any evidence of myocardial infarction. Esophagus disease of the reconstructed stomach conduit should be recognized as a rare but considerable cause for electrocardiographic changes.     

A pericardial hydatid cyst masquerading as acute inferolateral myocardial infarction--a case report

A case of pericardial hydatid cyst adjacent to the inferoposterial wall of the left ventricle is reported. Significant ST segment elevations in leads D2, D3, aVF, V5, and V6 on surface electrocardiography and sudden onset of severe chest pain mimicked acute inferolateral myocardial infarction. However, cardiac catheterization and coronary angiography showed normal coronary arteries and normal left ventricular cavity. The ST segment elevation in the inferolateral leads disappeared a few days after surgical resection of the cyst. Cardiac hydatid cyst should be considered in the differential diagnosis of patients with angina-like chest pain in endemic areas.     

Variant angina induced by biliary colic

A 65 year old woman with gall stones presented with crushing chest pain after an attack of biliary colic. The electrocardiogram showed ST segment elevation in leads I, aVL, and V1-V3 while leads II, III, and aVF showed ST segment depression. Cardiac enzyme activity remained within the normal range. During the next three weeks attacks of epigastric and right hypochondrial pain preceded by crushing chest pain with identical electrocardiogram changes occurred with decreasing frequency. Coronary arteriography showed 60% obstruction of the left anterior descending coronary artery and good left ventricular function. During the next three years the patient complained both of mild abdominal pain, probably biliary colic, and mild effort related angina pectoris without a relation between the two symptoms. It is suggested that the attack of variant angina was triggered by biliary colic through sympathoadrenal discharge causing vasospasm.