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Takotsubo cardiomyopathy — ABIM Board MCQ

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ModerateCardiovascularTakotsubo cardiomyopathyABIM Board

A 69-year-old woman develops crushing substernal chest pain shortly after learning of a family member's death. ECG shows anterior ST-segment elevations, and the serum troponin level is mildly elevated. Coronary angiography shows no obstructive coronary artery disease or culprit lesion. Left ventriculography demonstrates apical ballooning with hyperkinesis of the basal segments. Which of the following is the most likely diagnosis?

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Correct answer: A — Stress cardiomyopathy

The correct answer is A, stress cardiomyopathy (Takotsubo syndrome). It occurs most often in postmenopausal women after intense emotional or physical stress and can mimic an acute myocardial infarction with chest pain, ST-segment elevation, and modest troponin elevation. The decisive findings are the absence of a culprit coronary lesion and apical ballooning with basal hyperkinesis. Plaque rupture and spontaneous coronary artery dissection would ordinarily produce an angiographically identifiable culprit lesion. Coronary vasospasm can cause transient ST elevation with nonobstructive arteries but does not typically produce this characteristic ventricular contraction pattern. Acute myocarditis may cause chest pain, ST changes, and troponin elevation, but the stress trigger and classic apical ballooning pattern strongly favor Takotsubo syndrome.

Reference: American College of Cardiology. Takotsubo Syndrome: Expanding Insights, Unanswered Questions. 2024. https://www.acc.org/latest-in-cardiology/articles/2024/12/01/42/cover-story-takotsubo-syndrome-expanding-insights-unanswered-questions