What are the key clinical features that differentiate Takotsubo cardiomyopathy from other forms of acute coronary syndrome?

Takotsubo cardiomyopathy (TTC), also known as stress cardiomyopathy or apical ballooning syndrome, can mimic acute coronary syndrome (ACS) in its presentation, but several key clinical features help differentiate it NICE CG95 Prasad et al. 2008Yoshikawa 2015Ambrose & Albayati 2025.

• Coronary Angiography Findings: The most critical differentiating feature is the state of the coronary arteries. While ACS, which includes unstable angina, ST-segment-elevation myocardial infarction (STEMI), and non-ST-segment-elevation myocardial infarction (NSTEMI), is typically caused by obstructive coronary artery disease (CAD), TTC is characterized by the **absence of obstructive CAD** on coronary angiography NICE CG95 Prasad et al. 2008Yoshikawa 2015Ambrose & Albayati 2025.
• Left Ventricular Dysfunction Pattern: In TTC, there is a characteristic transient regional wall motion abnormality of the left ventricle, often presenting as apical ballooning, that extends beyond the distribution of a single epicardial coronary artery Prasad et al. 2008Yoshikawa 2015. This pattern is distinct from the regional ischaemia caused by a specific coronary artery occlusion in ACS NICE CG95.
• Precipitating Factors: TTC is frequently preceded by a significant emotional or physical stressor, such as sudden grief, fear, or intense physical exertion, which is a less common primary trigger for typical ACS Prasad etal 2008Yoshikawa 2015.
• Biochemical Markers: Both conditions can present with elevated cardiac troponin levels NICE CG95 Prasad et al. 2008Yoshikawa 2015. However, in TTC, the troponin elevation is often disproportionately lower compared to the extent of left ventricular dysfunction and the severity of ECG changes seen in a typical myocardial infarction Prasad et al. 2008Yoshikawa 2015.
• Electrocardiogram (ECG) Changes: Both ACS and TTC can present with ECG changes consistent with ischaemia, such as ST-segment elevation or T-wave abnormalities NICE CG95 Prasad et al. 2008Yoshikawa 2015. While these changes can be similar, the absence of obstructive CAD on angiography in the context of these ECG findings points towards TTC Prasad et al. 2008Yoshikawa 2015.
• Recovery of Ventricular Function: The left ventricular dysfunction observed in TTC is typically transient, with a full recovery of ventricular function usually occurring within weeks to months Prasad et al. 2008Yoshikawa 2015. While management of ACS aims for recovery, the underlying CAD remains, and myocardial damage can be permanent NICE CG95.