Can acute myocardial infarction sneak out from Takotsubo?

he new clinical entity of takotsubo cardiomyopathy (TC) was first introduced by Sato et al in 1990,1 8 years ahead of the first report on the condition from the United States. Dote et al reported 5 cases of TC in 1991.2 “Takotsubo” is an authentic Japanese ceramic pod with a narrow mouth used to trap octopus and its shape resembles the systolic left ventriculogram of TC patients. Other names used for the condition are “apical ballooning syndrome”, “broken heart syndrome”, and “stress cardiomyopathy”.3 Clinical and scientific interest in TC has dramatically increased since (ie, 2 publications in 2000, 50 or less per year before 2006, and nearly 300/year from 2008 to 2010).4 Although exaggerated sympathetic stimulation is thought to be central to this syndrome, the precise pathophysiological mechanisms have not yet been fully elucidated.4,5 Because there have been many informative papers from all over the world, the clinical features of TC are well established.3–7 Symptoms such as chest pain and shortness of breath develop abruptly, typically in postmenopausal women, after emotionally or physically stressful events. Emotional precipitants have reportedly included death of a family member or a pet, public speaking, financial loss, automobile accidents, and natural disasters such as earthquakes. TC is an acute cardiac syndrome with ST-segment elevation on 12-lead ECG and wall motion abnormalities in the apical and mid-portions of the left ventricle, despite the lack of obstructive coronary artery disease. These abnormalities on ECG and in wall motion extend beyond a single epicardial coronary distribution. Proposed Mayo clinic criteria have been used for the clinical diagnosis of TC.3 Because the symptoms and ECG findings of TC mimic those in patients with anterior acute myocardial infarction (AMI), from the clinical viewpoint, it is remarkably important, especially in the acute and subacute phases, to differentiate TC from AMI in order to apply appropriate therapeutic strategies. However, the differential diagnosis of TC and anterior AMI is often difficult. Recently, several reports have challenged the electrocardiographic differentiation of TC from AMI shortly after the onset of symptoms, with careful investigation of 12-lead ECGs.8–13