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A 69-year-old woman with extended negative T wave
  1. Keiji Matsunaga,
  2. Takahisa Noma,
  3. Tetsuo Minamino
  1. Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine Kagawa University, Kida-gun, Kagawa, Japan
  1. Correspondence to Dr Tetsuo Minamino, Cardiorenal and Cerebrovascular Medicine, Kagawa University, Kida-gun, Kagawa, Japan; minamino{at}med.kagawa-u.ac.jp

https://doi.org/10.1136/emermed-2019-208715

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    Clinical Introduction

    A 69-year-old woman with hypertension and dyslipidemia developed sudden onset of substernal chest pain at night and was admitted to our hospital the following day. A 12-lead and 18-lead ECG (Nihon Kohden, Japan) was done (figure 1A,B).

    Figure 1
    Figure 1

    (A) Twelve-lead ECG. (B) Eighteen-lead ECG.

    Question

    Which is the most likely diagnosis?

    1. Reperfused anterior acute myocardial infarction

    2. Takotsubo (stressed) cardiomyopathy

    3. Pericarditis

    4. Apical hypertrophic cardiomyopathy

    Answer

    B.Takotsubo (stress) cardiomyopathy

    Extended negative T waves in a 12-lead ECG can be found in patients with acute myocardial infarction (AMI), Takotsubo cardiomyopathy, pericarditis and apical hypertrophic cardiomyopathy. In this patient, pericarditis was unlikely because there was no ST-segment elevation or PR-segment depression.1 Hypertrophic cardiomyopathy was also unlikely because of the prolonged QT interval2 and the lack of negative T waves with a strain pattern. However, it was challenging to differentiate an AMI from a Takotsubo cardiomyopathy with a 12-lead ECG.

    Negative T wave locations in an 18-lead ECG provide the critical clue to differentiate between the two diseases.3 Negative T waves in precordial (V1, V2, V3, V4), inferior (especially in II) and posterolateral (V6, syn-V7, syn-V8 and syn-V9) leads reflect pathological conditions of the anterior, inferior and posterolateral myocardium the possibility of a Takotsubo cardiomyopathy should be strongly considered because simultaneous changes in these leads in an AMI is extremely rare.

    References

    1. ↵
      2. LeWinter MM
      . Acute pericarditis. N Engl J Med Overseas Ed 2014;371:2410–6.doi:10.1056/NEJMcp1404070
      OpenUrl
    2. ↵
      2. Kosuge M ,
      3. Ebina T ,
      4. Hibi K , et al
      . Differences in negative T waves between takotsubo cardiomyopathy and reperfused anterior acute myocardial infarction. Circ J 2012;76:462–8.doi:10.1253/circj.CJ-11-1036
      OpenUrlCrossRefPubMedWeb of Science
    3. ↵
      2. Ashida T ,
      3. Tani S ,
      4. Nagao K , et al
      . Usefulness of synthesized 18-lead electrocardiography in the diagnosis of ST-elevation myocardial infarction: a pilot study. Am J Emerg Med 2017;35:448–57.doi:10.1016/j.ajem.2016.11.052
      OpenUrl

    Footnotes

    • Contributors All authors have contributed to the conception of the paper and the interpretation of the data.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; internally peer reviewed.