Mild ST-segment Elevation Research Articles

Flow diagram of the differential diagnosis and clinical decision making in a rare case of contrast-induced encephalopathy following cardiac catheterization: a case report

BackgroundContrast-induced encephalopathy (CIE) is considered as an uncommon complication following cardiac catheterization. Due to the varied manifestations, CIE has no formal diagnostic criteria. In fact, the incidence of CIE may be greatly underestimated because of the difficulty in its differential diagnosis with other cerebrovascular complications. Thus, making a flow diagram according to patients’ clinical symptoms and examinations after cardiac catheterization to help clinicians diagnose CIE is important and needed.Case presentationIn this report, we describe a case of probable CIE in a 66-year-old Chinese man with hypertension who underwent cardiac catheterization with stents placement in the bifurcation lesion, during which 80 ml iopromide contrast was used. About 2 h following the procedure, the patient lost his consciousness suddenly and suffered from a status epilepticus. Malignant arrhythmias were not found through continuous electrocardiogram monitoring, but mild ST-segment elevation was displayed in leads I and aVL. The echocardiography, plasma glucose and electrolyte levels were normal. Emergency re-angiography with percutaneous transluminal coronary angioplasty was performed in the culprit lesion, which involved 60 ml iopromide contrast. However, the patient remained unconsciousness and epilepticus. Non-contrast computed tomography (CT) of the head showed cortical and subarachnoid enhancement as well as prolonged retention of contrast media in the middle cerebral artery. With supportive treatment of intravenous hydration, sedative and dehydrant, the patient recovered 3 h later and finally discharged without any neurological deficits.ConclusionsCIE is an acute reversible encephalopathy induced by contrast media. It is exceptionally challenging to make the diagnosis of CIE following cardiac catheterization since there is a lack of consensus on the definition of CIE. Via this case we reviewed the related literatures, through which a flow diagram of the differential diagnosis and clinical decision making was given, which could help to differentiate CIE from other neurological complications following cardiac catheterization.

434 TAKOTSUBO SYNDROME AFTER PACEMAKER IMPLANTATION

Abstract Introduction Takotsubo syndrome is a clinical syndrome characterized by typical anamnestic features together with typical ECG and echocardiographic findings. Comparing with the available literature not so many cases of takotsubo syndrome after pacemaker implantation can be found. Furthermore, there are only few articles talking about ECG features in these patient. The case we described allows to observe dynamic ECG alterations in a patient with electro-induced ventriculograms Case Description A 90-year-old male was admitted to the emergency room for important fatigue associated with severe bradycardia (25/min). His cardiovascular history was silent, and his past medical history was characterized by high blood pressure, chronic pulmonary obstructive disease and anemia due to iron deficiency. The ECG showed second degree AVB type 2, with phases of 2:1 AVB and paroxysmal third degree AVB on continuous monitoring. The routine blood tests showed normal T troponin and BNP was 420 pg/mL. The echocardiogram revealed normal biventricular dimensions and systolic function with moderate aortic valve stenosis. The patient underwent urgent permanent DDD pacemaker implantation without previous isoproterenol administration. During the procedure he referred important pain on the site of the wound, and he became confused and agitated. The procedure was complicated by massive pneumothorax that needed quick decompression. On the 2nd day after pacemaker implantation the ECG revealed electro-induced atrium-guided ventriculograms and began to modify with only mild ST-segment elevation in V2 and initial T-wave inversion from V3 to V6 and in I - II - aVF. On the next days, T-waves became deeper and QTc prolonged to 540 ms. These abnormalities were then gradually resolved on the 11th day. Mild transient attenuation of the amplitude of the QRS complexes in V2 – V3 leads on day 1 could be reported. Another echocardiogram was then performed, which showed new apical akinesis with “apical ballooning” aspect and EF of 40%. TnT and BNP values increased. Coronary angiogram was not performed due to patient rejection, so that coronaropathy could not be excluded with certainty. Nevertheless, the patient had only high blood pressure as cardiovascular risk factor and that the probability of the diagnosis of takotsubo cardiomyopathy was assessed of 76,9% by InterTAK diagnostic score, so that we considered Takotsubo syndrome the most likely diagnosis. Therefore, the patient's therapy was then optimized with an increase in the dosage of ACE inhibitors. At one month follow-up the ECG remained stable, and the echocardiogram showed a preserved ejection fraction (EF = 55%), without alterations of the segmental contractility. BNP and TnT values were normal. Therapy was left unmodified. Conclusions Takotsubo syndrome should be consider a rare but possible complication of pacemaker implantation. This is true especially for patients affected by frailty and cognitive impairment. There are no specific ECG criteria for takotsubo syndrome in patients with electro-induced ventriculograms, but anomalies of the repolarization are similar to those in patients with spontaneous ventricular activity. Transient attenuation of the QRS complexes voltages could be seen even just in the precordial leads and it is generally present in the very acute phase.

Is COVID-19 the New Atherosclerosis? Acute Aortic Dissection Type A in the Early Period after COVID -19 Infection

The novel corona virus pandemic has since spread rapidly throughout the world resulting in more than 400 million cases. The clinical manifestations and complications associated with COVID-19 is yet to be elucidated. The clinical presentation may be variable, as it has been previously described. In the published literature many cases of acute aortic dissection caused by COVID-19 infection have been described, but only one in the early period after the resolution of the infection. We present a39year-oldwoman, who was admitted to our department complaining of chest pain after the yoga session. Her past medical history was notable for COVID-19 infection two weeks ago. Her electrocardiogram showed sinus rhythm and mild ST segment elevation in lead a VR, while the transthoracic echocardiogram revealed a dilation of the ascending aorta. After the echocardiographic examination, contrast enhanced computed tomography of aorta was conducted, which revealed an acute aortic dissection (type A- Stanford classification). The patient was admitted for emergent cardiovascular surgery, that was successful and eventually was discharged at the ninth post-operative day.

P302 ENDOTHELIALITIS AS A POSSIBLE CAUSE OF MYOCARDIAL INJURY DURING COVID–19 INFECTION

A 53–year–old woman was admitted for chest pain for over two weeks, fever, dry cough, fatigue and myalgia. Chest pain increased in supine position and inspiration. Nasopharyngeal swab was positive for SARS–CoV–2 RT–PCR assay. Admission ECG displayed mild ST–segment elevation (0,5 mm) in inferolateral leads and echocardiogram showed normal left ventricular volume, mildly decreased left ventricular EF (52%) and no regional wall motion abnormalities. Blood tests exhibited elevated values of high–sensitivity troponin I (818 pg/mL), proBNP (19.190 pg/mL), CRP (42 mg/dL), D–Dimer test (1090 ng/mL) and WBC (13000/uL, N 89%, L 7%). IL–6 resulted slightly increased (18 ng/mL). ECG after 24 hours showed T wave inversion in inferolateral leads. Coronary CT angiography revealed normal epicardial arteries. A new echocardiogram, after five days, showed infero–basal hypokinesia, improved global EF (57%) and minimal pericardial effusion. Aspirin and fondaparinoux were started. Myopericarditis was suspected and high dose steroids were administered. After a few days, symptoms improved and ECG, echocardiographic abnormalities and troponin levels were normalized. At 6 weeks follow–up the patient was asymptomatic, ECG and echocardiogram were both normal. Instead cardiac MRI showed signs of endothelial injury: presence of interstitial oedema in the inferoapical and anteroseptal wall (STIR–T2–weighted), without late gadolinium enhancement. We measured blood levels of endothelial dysfunction markers: soluble ICAM–1, VCAM–1 and von Willebrand factor (vWF). They all resulted elevated as compared to a laboratory pool of normal serum (535 ng/ml, 265 ng/ml, and 1659 ng/ml, respectively). Our case was suggestive of myopericarditis related to Sars–Cov–2, but echocardiogram and MRI did not show signs of myocarditis permanent damage. However MRI showed interstitial oedema and hyperemia, typical signs of endothelial injury. Moreover we found high levels of soluble endothelial adhesion molecules, vWF, ICAM–1 and VCAM–1, likely expression of the microcirculatory endothelial dysfunction due to myocardial endothelialitis.In conclusion, our case report suggests that, in COVID–19, acute myocardial injury associated with clinical and investigational signs of myocarditis can be due to myocardial endothelialitis rather than true myocarditis and that an early management with anti–inflammatory drugs (steroids) can be particularly beneficial in patients with unexplained elevated cardiac troponin.

Is It ST-Segment-Elevation Myocardial Infarction?

A 76-year-old man presented with acute-onset chest pain and dyspnea. He had a history of coronary artery disease, ischemic cardiomyopathy (left ventricular ejection fraction, 25%), recent non-ST-segment-elevation myocardial infarction (NSTEMI), and stenting of the left anterior descending coronary artery (LAD) one month before the current presentation. Soon thereafter, he underwent stenting of the left main coronary artery (LMCA), obtuse marginal branch (OMB), and left circumflex coronary artery. His chest pain subsided soon after arrival at the emergency department. His cardiac troponin I level was 22 ng/mL (normal level, <0.03 ng/mL), and his brain natriuretic peptide level was 841 pg/mL (normal level, <100 pg/mL). Figure 1 shows his electrocardiogram (ECG).What is the diagnosis?C) STEMI due to first OMB or ramus intermedius occlusionThe ECG shows sinus rhythm, mild ST-segment elevation (STE) with T-wave inversion in lead aVL, ST-segment depression with positive T waves in leads II, III, aVF, and V3 through V6, and an isoelectric ST segment in leads I and V1 through V2. The Fourth Universal Definition of Myocardial Infarction1 says, “More profound ST-segment shifts or T-wave inversions involving multiple leads/territories are associated with a greater degree of myocardial ischaemia, and a worse prognosis. For example, ST-segment depression ≥1 mm in 6 leads, which may be associated with STE in lead aVR or lead V1 and hemodynamic compromise, is suggestive evidence of multivessel disease or left main disease” (eliminating answer A). This is considered a high-risk ECG pattern for which invasive intervention within 2 hours is recommended, in accordance with the 2020 European Society of Cardiology guidelines for managing acute coronary syndromes without persistent STE.2 Our patient's ECG shows ST-segment depression in 7 leads but no significant STE in lead aVR or V1. In contrast, STE with negative T waves is seen in lead aVL.Patients with a nonischemic early repolarization pattern can have STE in lead aVL. However, the T waves are usually positive, and there is often a J-point notch. The pattern here suggests a reperfused or more advanced stage of STEMI,3 and the patient's clinical presentation (symptom resolution after hospital arrival) supports this diagnosis.New STE in 2 contiguous leads is necessary for the diagnosis of STEMI.1 However, this is an epidemiologic (not pathophysiologic) criterion, to minimize false-positive diagnosis. Acutely occluded arterial branches may cause STE in only one lead with diffuse ST-segment depression.4 The STE in leads aVL and V2 through V5 is caused by LAD occlusion proximal to the first diagonal branch (eliminating answer B),4 and STE in leads aVL and V2 without STE in leads V3 through V5 suggests an occluded first diagonal branch. The ST-segment depression in the anterolateral and inferior leads is incompatible with the typical presentation of takotsubo cardiomyopathy (answer D). The STE in lead aVL, incompatible with ischemic cardiomyopathy (answer E), is accompanied by ST-segment depression in lead V2, suggesting obstruction of the first OMB. Our patient had an isoelectric ST segment in lead V2, so the differential diagnosis is an occluded OMB or ramus intermedius.4 A coronary angiogram on the second day of admission showed subacute thrombotic occlusion of the first OMB (Fig. 2, arrow), and stenting restored patent flow.Disclosures: NoneFunding/support: None

ST elevation myocardial infarction equivalent - De Winter T-wave electrocardiography pattern

Introduction. Rapid diagnosis of acute myocardial infarction is essential for proper treatment and reduction of patient mortality. Electrocardiography plays an important role in its diagnosis. Acute myocardial infarction with ST segment elevation requires urgent reperfusion therapy, that is, primary percutaneous coronary revascularization. A small number of patients with acute myocardial infarction have ST segment depression in one or more leads, whereas ST segment elevation in augmented vector right the electrocardiogram is characteristic for a myocardial infarction without ST elevation, but the clinical course and the severity of disease correspond to the anterior myocardial infarction with ST segment elevation. De Winter T-wave electrocardiography. One of these forms is known as de Winter T-wave pattern, characterized by ST segment depression at the J-point (> 1 mm) in the precordial leads, the absence of ST segment elevation in the precordial leads, high peaked and symmetrical T-waves in the precordial leads and, in most cases, mild ST segment elevation (0.5 mm to 1 mm) in the augmented vector right. These patients have occlusion of the left main coronary artery, occlusion of the proximal segment of the anterior descending artery, or a severe multivessel coronary disease. Patients with this electrocardiographic pattern, which is equivalent to acute myocardial infarction with ST segment elevation, require consideration of emergency reperfusion therapy due to high mortality, compared to other patients with acute myocardial infarction without ST elevation. Primary percutaneous intervention is recommended, or if there is no catheterization laboratory nearby, fibrinolytic therapy may be considered. Because of the lack of clear recommendations, treatment decisions are made individually, from case to case. Conclusion. We need large pro?spective studies with this specific electrocardiographic pattern to provide quick recognition and proper treatment of the anterior myocardial infarction with ST elevation.

Right ventricular marginal branch occlusion after blunt force trauma to the chest

Coronary artery occlusion following a blunt trauma is a rare complication. We report a case of a 56-year-old man who experienced an intermediate code trauma following a motor vehicle accident. The patient had a visible ‘seat-belt sign’ and complained of chest pain. Initial electrocardiogram showed mild ST segment elevation accompanied by elevation of cardiac enzymes. Echocardiogram and cardiac magnetic resonance imaging were consistent with right ventricular systolic dysfunction. Coronary angiogram revealed 100% occlusion of proximal right ventricular marginal branch. The patient was managed medically. This case presents a rare case of right ventricular marginal occlusion following blunt chest trauma.

High-Risk Percutaneous Coronary Intervention in the Era of Public Reporting

A 73-year-old white woman presented to a community hospital emergency department with 7 days of productive cough, dyspnea, and fatigue. Her vital signs were as follows: temperature, 99.9°F; pulse, 100 bpm; respiratory rate, 16 breaths per minute; blood pressure, 153/78 mm Hg; and oxygen saturation, 97% on room air. Her jugular venous pressure was normal; her lungs were clear; and her cardiac examination demonstrated tachycardia but no murmurs or gallops. Extremities were warm without edema. Her complete blood count was normal with the exception of a mild leukocytosis (13 000 cells/mm3). Her electrolytes and renal function were normal (creatinine, 0.8 mg/dL). Her troponin T level was <0.01 ng/mL. A chest radiograph demonstrated a subtle right middle lobe infiltrate. Intravenous ceftriaxone and azithromycin were given for community-acquired pneumonia. Relevant medical history included hypertension, hyperlipidemia, and an ischemic stroke 21 months previously that resulted in residual right hemiplegia. She had no history of cardiac disease. The patient was married and lived at home with her husband, who assisted her with many of her activities of daily living. While in the emergency department, the patient became unresponsive, and ventricular fibrillation was detected on the telemetry monitor. Cardiopulmonary resuscitation was delivered for 3 minutes, and sinus rhythm was restored after 1 defibrillatory shock. The patient was subsequently intubated for airway protection and loaded with intravenous amiodarone, and an ECG was obtained (Figure 1). Hypotension ensued over the next 10 minutes, and dopamine was initiated for hemodynamic support. Requests were made to transfer the patient to a tertiary care facility with 24-hour cardiac catheterization capability. Figure 1. ECG showing diffuse ST-segment depressions in the precordial leads and mild ST-segment elevation in lead aVR. There is also isolated 1-mm ST-segment elevation in lead III with nonpathological Q waves in the inferior leads. Dr Yeh: The patient’s initial …

Apical ballooning with mid-ventricular obstruction: the many faces of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) is a transient left ventricular dysfunction due to akinesia of the left-ventricular (LV) mid-apical segments (apical ballooning), which can cause severe reduction in LV systolic function. The typical clinical picture of TTC include chest pain, electrocardiographic changes consisting of mild ST-segment elevation followed by diffuse deep T-wave inversion, QTc interval prolongation and mild troponin release in the absence of significant coronary stenoses. The syndrome often affects post-menopausal women and is triggered by sympathetic overstimulation, like intense physical or emotional stress, so that it is called the “broken heart syndrome”. Although left-ventricular systolic dysfunction usually fully recovers within few days, heart failure can still complicate the early phase. We report a case of stress-induced cardiomyopathy that had full recovery after 4 weeks of follow up. The main electrocardiographic, angiographic and imaging features are discussed.

Improved angiographic findings in a high risk acute coronary syndrome patient after modest weight reduction, regular exercise and medication: A case report and literature review

A 55-year-old, morbidly obese man body weight&nbsp;(BW)&nbsp;of 104 kg, body mass index&nbsp;(BMI)&nbsp;of 30.5 kg/m2 with known history of type 2 diabetes mellitus, hypertension, dyslipidemia and primary hypothyroidism, presented with acute chest pain and heart failure in 2007.&nbsp;Frank pulmonary edema and cardiomegaly were documented from admission chest film&nbsp;(Figure 1).&nbsp;The electrocardiogram&nbsp;(ECG) (Figure 2)&nbsp;showed sinus tachycardia, left atrial enlargement, tall R in V2 with ST depression in V2-4, Q wave and mild ST segment elevation in inferior leads.

ST-segment elevation and ventricular tachycardia after ingestion of a common ornamental plant—a case report

Japanese yew is a widely used ornamental plant. However, most people are unaware that it is also a poisonous plant. It has potent cardiac toxicities that can lead to sudden cardiac death.A 37-year-old female patient presented to the emergency room with altered mental status and sustained ventricular tachycardia (VT). Electrocardiogram (ECG) after cardioversion showed profound QRS prolongation and ST-segment elevation suggestive of either hyperkalaemia, acute myocardial ischaemia, or Brugada syndrome. Her electrolytes and coronary angiography were normal.After improvement of the patient's mental status, she admitted that she has been consuming Japanese yew from her yard for several months. Few hours later, QRS duration normalised, but mild ST-segment elevation persisted in the right pre-cordial leads, making it more suspicious for Brugada syndrome. However, a procainamide challenge test and electrophysiology study failed to induce typical Brugada pattern ECG and VT. The absence of coronary artery disease and electrolytes disturbances points toward the fact that her arrhythmia and ECG changes are secondary to yew intoxication. The patient was monitored for a few days. She was haemodynamically stable and has not had any arrhythmia.This case highlights the importance of public awareness of severe toxicity from Japanese yew or other yew plants. Yews contain taxines that are responsible for the ECG abnormalities due to its inhibitory effect on the cardiac sodium and calcium channels. They cause conduction abnormalities, VT, and ST-segment elevation that can resemble acute myocardial infarction, hyperkalaemia, and Brugada syndrome.

Multiple Coronary Artery Thrombosis in 5,10-Methylenetetrahydrofolate Reductase Gene Mutation

A 42-year-old man presented at our attention with chest pain. His cardiac risk factors were smoking habit and family history of coronary artery disease. At the ECG, a mild ST-segment elevation in the inferior leads was shown. A normal left ventricular function was demonstrated at the echocardiography. An emergency coronary angiography was performed, and an extensive thrombosis of the right coronary artery and midleft anterior descending coronary artery was visualized. A primary angioplasty with thrombus aspiration and direct stenting of both sites followed. Biochemical analysis revealed a high plasma homocysteine level with a homozygotic anomaly of the 5,10-methylenetetrahydrofolate reductase. Currently, a nine-month followup negative for cardiac events is recorded.

A Case of Idiopathic Ventricular Fibrillation Triggered by Premature Ventricular Contraction Originating from Right Ventricular Outflow Tract

A 28 year-old man without any heart disease suddenly fell down in a train and was admitted to our hospital after complete resuscitation by automated external defibrillator. Various cardiac examination were performed to clarify the cause of cardiopulmonary arrest. Coronary angiography showed normal coronary artery, and acetylcholine provocation test and exercise stress test were negative. No structural heart disease was revealed by cardiac MRI and echocardiogram. Brugada syndrome was suspected because of mild ST-segment elevation in the right precordial leads, however intravenous pilsicainide did not elicit typical coved type pattern. On a continuous electrocardiogram monitoring, there were frequent monofocal premature ventricular contractions (PVCs) originating from right ventricular outflow tract (RVOT), and some of them developed into nonsustained polymorphic ventricular tachycardia. Considering from these results, he was highly suspected having idiopathic ventricular fibrillation (VF) triggered by PVC of RVOT origin. Radiofrequency catheter ablation (RFCA) was performed and no polymorphic ventricular tachycardia was induced by any stimuli after RFCA. An implantable cardioverter defibrillator (ICD) was also implanted, and no shock has been delivered after hospital discharge. We experienced malignant type of idiopathic VF triggered by PVC from RVOT, and combination therapy of RFCA and ICD would be effective in this case.

546 The Diagnosis of Myopericarditis in An Adolescent with Anxiety Disorder Presenting with Chest Pain

Background: Chest pain is a common symptom in children and adolescents and has important functional consequences since it may result in restriction of activities, school absenteeism and anxiety in the family. Nevertheless, it's frequently underestimated, especially in adolescence. Case report: A 15-year-old male adolescent, followed as an outpatient by Pedopsychiatry for several years for an anxiety disorder, but otherwise healthy, presented with dull anterior chest pain, more intense in the precordium, which awaked him during the night, subsisting in the morning. The pain had no irradiation and exacerbated with respiratory movements. He complained of dry cough and myalgias since the day before. In the physical examination, was apyretic, hemodynamically stable and a pericardial friction rub was evident in auscultation. Three days ago, he presented a tooth abscess, for which he was taking roxitromicin (600mg/ kg/day). Electrocardiogram showed low voltage in all member derivations, early depolarization and mild ST segment elevation (∽1mm) with upper concavity in all derivations. Two-dimensional echocardiography showed no relevant findings. Blood tests revealed no inflammatory markers rise but considerable troponin I (4.56ng/mL) and CKMB (24.00ng/mL) elevation. Serologies and PCR detection of viral genome were performed. He was treated in ambulatory regimen with acetylsalicylic acid (100mg/kg/day). Comments: In this case, a thorough history and physical examination, along with electrocardiogram and laboratory testing, revealed an organic cause for chest pain that could otherwise have been undiagnosed or attributed to a psychogenic cause. Despite the benign course of this case of myopericarditis, without adequate treatment it could have gone differently.

Tako-tsubo cardiomyopathy after successful resuscitation of out-of-hospital cardiac arrest

A 69-year-old woman and a 29-year-old man were admitted to our hospital after successful resuscitation of out-of hospital cardiac arrest. In the first case, electrocardiogram showed mild ST-segment elevation in leads V3-V5. Coronary angiography did not show any obstructive coronary artery disease, and left ventriculography showed apical ballooning of the left ventricular chamber. She was diagnosed as having the classic form of tako-tsubo cardiomyopathy. In the second case, electrocardiogram did not show ST-segment elevation in any lead. Coronary angiography showed no coronary artery disease and left ventriculography showed basal ballooning of the left ventricular chamber. He was diagnosed as having the variant form of tako-tsubo cardiomyopathy. In both cases, left ventricular function returned to normal, but they died of multiple organ failure. In conclusion, cardiologists should recognize that takotsubo cardiomyopathy can occur even after successful resuscitation of cardiac arrest. Early diagnosis and appropriate intensive care are essential in these critically ill patients.

A Case of Myocardial Infarction Caused by Coronary Vasospasm: Efficacy of Soluble Lectin-Like Oxidized LDL Receptor-1 for Distinguishing between Vasospasm and Plaque Rupture

This case illustrates the benefits of using plasma levels of soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) to distinguish between myocardial injuries caused by coronary vasospasm or coronary plaque rupture. A 62-year-old woman with a history of dyslipidemia was admitted due to chest pain of 1 hour's duration. Electrocardiography demonstrated mild ST segment elevation in leads V1-6, and blood chemistry studies on admission showed a slight increase in the serum level of troponin T; therefore, acute myocardial infarction was diagnosed. However, the plasma level of sLOX-1, a marker of plaque rupture, did not increase during hospitalization. Coronary angiography demonstrated normal coronary arteries, and intracoronary acetylcholine infusion provoked coronary artery vasospasm. We could therefore diagnose myocardial injury caused by coronary vasospasm. We propose that the cause of myocardial injury cannot be predicted with electrocardiography and measurement of troponin T but can be clarified by measuring plasma levels of sLOX-1 in the early stage of acute coronary syndrome.

Tako-Tsubo Phenomenon: Dual-Source Computed Tomography and Conventional Coronary Angiography

A 75-year-old woman was admitted to our emergency department with severe chest pain and mild dyspnea that started soon after a marital quarrel with her husband. Her 12-lead electrocardiogaphy (ECG) demonstrated an ST elevation in the precordial leads, and the plasma troponin T level was elevated to 0.29 ng/mL. An acute myocardial infarction with ST elevation was assumed, and the patient was admitted for an emergency catheter coronary angiography. Her coronary arteries were normal, but left ventriculography demonstrated a severe systolic dysfunction involving the mid and apical myocardial segments, showing apical ballooning (Supplemental Data Movie I). Thus, the diagnosis of tako-tsubo phenomenon was made. The ejection fraction was decreased to 40%. Because of a history of pulmonary embolism, the patient was referred for chest computed tomography (CT) to rule out a recurrent pulmonary embolism. Contrast-enhanced, retrospectively ECG-gated dual-source CT excluded pulmonary embolism and similarly demonstrated systolic dysfunction with apical ballooning (Supplemenal Data Movie II). After 2 days, the patient’s symptoms ceased and echocardiography showed normalized left ventricular systolic function. Tako-tsubo phenomenon is characterized by transient left ventricular systolic dysfunction of unknown etiology. Initially described in Japan [1] and named after an octopustrapping pot with a round bottom and a narrow neck, it has also been recognized more and more in Western countries [2, 3]. It predominantly occurs in postmenopausal women and frequently after emotional stress. Importantly, such a psychological stressful trigger is not observed in all individuals, and its absence does not exclude the diagnosis. A few cases have been reported in younger women and males [4]. Rarely, patients present with syncope or an out-ofhospital cardiac arrest. Symptoms clinically mimic acute myocardial infarction, with the majority of patients presenting with chest pain, dyspnea, and mild ST-segment elevation in precordial leads followed by T-wave inversion involving most leads [2]. Plasma troponin T levels are either normal or only slightly increased and thus contrast the extent of systolic dysfunction in the acute phase. Patients are usually hemodynamically stable, but clinical findings of mild to moderate congestive heart failure commonly coexist. In a minority of patients, hypotension may occur from reduced stroke volume and occasionally from dynamic left ventricular outflow tract obstruction. Cardiogenic shock may be a rare complication. Patients with tako-tsubo phenomenon generally have a good prognosis in the absence of significant underlying comorbidity. The systolic dysfunction and the regional wall-motion abnormalities are transient and full recovery usually occurs in most cases without specific therapy [2, 3]. The initial imaging for patients with tako-tsubo phenomenon is usually performed with catheter coronary angiography because of the clinical suspicion of acute myocardial infarction. The left ventriculogram shows characteristic regional wall-motion abnormalities involving the mid and apical segments (Fig. 1). There is sparing of the basal systolic function, and the wall-motion abnormality extends beyond the distribution of any one single coronary artery. Apical sparing variants have also been described [5]. Echocardiography and magnetic resonance H. Scheffel P. Stolzmann C. Karlo B. Marincek H. Alkadhi (&) Institute of Diagnostic Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland e-mail: hatem.alkadhi@usz.ch

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.

Apical Ballooning Syndrome

Case presentation: A 60-year-old woman presented to the emergency department 2 hours after the onset of severe retrosternal chest pain that started soon after she was told that her son had died in a car accident. A 12-lead ECG demonstrated ST-elevation in the precordial leads (Figure 1), and the plasma troponin T level was elevated at 0.07 ng/mL. A diagnosis of acute ST-elevation myocardial infarction was made, and the patient was admitted for emergency coronary angiography, which revealed normal coronary arteries. The left ventriculogram showed severe systolic dysfunction involving the mid and apical segments (Data Supplement Movie I). Figure 1. Twelve-lead ECG demonstrating ST-segment elevation in precordial leads. Physicians have long been aware of the possible association between stress and cardiovascular events. Awareness has increased of a distinct cardiac syndrome that was originally described in the Japanese population and was called Takotsubo cardiomyopathy, named after the octopus-trapping pot with a round bottom and narrow neck that resembles the left ventriculogram during systole in these patients.1,2 Other names used to describe the condition include apical ballooning syndrome (ABS), broken heart syndrome, and stress or ampulla cardiomyopathy. The precise incidence of ABS is unknown, but it may account for 1% to 2% of patients who present with an acute myocardial infarction.3 The majority of patients have a clinical presentation that is indistinguishable from an acute coronary syndrome. Most present with chest pain at rest, although some patients have dyspnea alone as their initial presenting symptom. Rarely, patients present with syncope or an out-of-hospital cardiac arrest.4 ABS appears to occur almost exclusively in postmenopausal women; however, a few cases have been reported in younger women and males.4 The patients are usually hemodynamically stable, but clinical findings of mild-to-moderate congestive heart failure …

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.