What is the role of ECG in the diagnosis of takotsubo (stress) cardiomyopathy (broken heart syndrome)?

Updated: Jul 31, 2019
  • Author: Eric B Tomich, DO; Chief Editor: Erik D Schraga, MD  more...
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Answer

As with any patient in whom acute coronary syndrome (ACS) is suspected, electrocardiography (ECG) should be the initial test obtained soon after presentation to the emergency department. ST-segment elevation (67-75%) and T-wave inversion (61%) are the most common abnormalities seen on the initial ECG. Ninety-five percent of ST-segment elevations have been found to involve the precordial leads and to be maximal in leads V2 -V3. In comparison with patients with ST-segment elevation myocardial infarction (STEMI) from left anterior descending (LAD) coronary artery occlusion, patients with takotsubo cardiomyopathy had significantly lower amplitude of ST-segment elevations. (See the images below.)

Takotsubo (stress) cardiomyopathy (broken heart syndrome). Electrocardiogram of a patient with takotsubo cardiomyopathy demonstrating ST-segment elevation in the anterior and inferior leads.

Takotsubo (stress) cardiomyopathy (broken heart sy Takotsubo (stress) cardiomyopathy (broken heart syndrome). Electrocardiogram of a patient with takotsubo cardiomyopathy demonstrating ST-segment elevation in the anterior and inferior leads.

Takotsubo (stress) cardiomyopathy (broken heart syndrome). Electrocardiogram (ECG) from the same patient discussed in the previous ECG, obtained several days after the initial presentation. This ECG demonstrates resolution of the ST-segment elevation, and now shows diffuse T-wave inversion and poor R-wave progression.

Takotsubo (stress) cardiomyopathy (broken heart sy Takotsubo (stress) cardiomyopathy (broken heart syndrome). Electrocardiogram (ECG) from the same patient discussed in the previous ECG, obtained several days after the initial presentation. This ECG demonstrates resolution of the ST-segment elevation, and now shows diffuse T-wave inversion and poor R-wave progression.

An initially normal or nonspecific ECG finding is seen in 15% of patients with takotsubo cardiomyopathy. Diffuse T-wave inversions tend to occur in the days and weeks following presentation as the ST segments normalize. takotsubo cardiomyopathy cannot be reliably differentiated from STEMI solely on the basis of ECG findings. [26, 30]

In a retrospective study of 33 patients with takotsubo cardiomyopathy, the authors proposed ECG criteria to distinguish takotsubo cardiomyopathy from anterior acute MI in those who presented within 6 hours of symptom onset. The combination of absent abnormal Q waves, absent reciprocal changes, lack of ST-segment elevation in lead V1, and presence of ST-segment elevation in lead aVR had more than 91% sensitivity and 96% specificity for takotsubo cardiomyopathy. [42]


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