Tako-tsubo Cardiomyopathy and its multiple variants

Tako - Tsubo Cardiomyopathy

The correct answer is a Tako-Tsubo Cardiomyopathy. [Stress cardiomyopathy or broken heart syndrome]. Typical presentation is a patient with chest pain after emotional distress and EKG presentation suggestive of an ST elevation myocardial infarction.[ST elevation]



ST elevation myocardial infarction is not entirely an incorrect answer. The patient still is treated initially as a STEMI, but then in the catheterization laboratory the usual findings are no significant obstructive coronary artery disease with typical ballooning of the apex of the heart on left ventriculogram. Therefore the syndrome was also called apical ballooning syndrome or Octopus trap syndrome, first described in the mid 1980s by a Japanese scientist

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However more recently several variants have been noted, one variant is where there is akinesis of the mid ventricle and hypercontractility of the apex and the base [see article] and yet another form is reversed Tako-Tsubo syndrome, or also called “squid syndrome”. This gives an image on ventriculogram and echocardiogram with apical hypercontractility and basilar akinesis




There are specific ECG criteria that differentiates Tako-Tsubo Cardiomyopathy from a true STEMI secondary to plaque rupture or type I myocardial infarction.



Although this EKG looks like an ST elevation myocardial infarction , the distribution of the ST segment elevation is unusual as well as the shape of the ST segments. There is also no reciprocal ST segment depression. The frontal axis is typically shifted more leftward.

The EKG at first glance can also look like pericarditis, but the history is not compatible with this and although there are a few leads with what appears to be PR depression there is no PR elevation in aVR and is also no ST elevation in all leads and/or T wave inversion. Squid syndrome ( reverse tako -tsubo syndrome) presents with ST depression and QTC prolongation. No J wave's are seen which would be associated with hypothermia, hypercalcemia, idiopathic VT or even Brugada syndrome.



The point of this question is to alert you that when elderly people complain of a "bad dream" or go through emotional/physical distress and then develop chest pain, and particularly when they complain of associated shortness of breath either at rest or on exertion, always keep this syndrome and its multiple variants in mind. Call EMS and get an EKG in the interim if you can, and if not one available call EMS and refer the patient to the hospital. Often the patient will minimize her/his symptoms and and will say "it's nothing and just felt bad".There is no reason to remember all the criteria and EKG features, as the answer lies in the patient's history. Often this is a benign syndrome but not always.Also this patient has 3+ ( on a scale of 4) mitral regurgitation and likely presented with crackles and left sided heart failure symptoms. The other video I attached is a NC female school bus driver , who ended up in a ditch and some of the kids were hurt . She was emotionally so shaken she developed also a stress cardiomyopathy

Attached articles

Here is the distribution of the answers of the initial 25 answers.