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).
Which is the most likely diagnosis?
Reperfused anterior acute myocardial infarction
Takotsubo (stressed) cardiomyopathy
Apical hypertrophic cardiomyopathy
Which is the most likely diagnosis?For answer see page 2.
- cardiac care, diagnosis
- cardiac care, acute coronary syndrome
- ECG, methods
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For question see page 1.
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.
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.
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