Left ventricular apical ballooning syndrome (LVABS) is a clinical condition that may mimic ST-elevation acute myocardial infarction (AMI). To assess incidence, clinical findings, and outcome of white women with LVABS, we reviewed 305 consecutive women with chest pain and anterior ST-elevation AMI referred for potential mechanical revascularization; 36 (12%) patients met the diagnostic criteria for LVABS and were compared with the remaining 269 women with angiographic evidence of coronary artery disease (CAD). Patients with LVABS showed a lower incidence of diabetes mellitus (5% vs 21%, p = 0.023), a higher rate of antecedent stressful events (26% vs 3%, p <0.0001), and a higher heart rate at admission (91 +/- 20 vs 82 +/- 19, p = 0.018) than women with CAD. Urgent angiography showed no significant CAD in patients with LVABS and an average of 1.6 +/- 0.7 diseased coronary arteries (>50% stenosis) in the 269 control women (p = 0.0001). Peak creatine kinase-MB value was lower in patients with LVABS (21 +/- 26 mU/ml) than in women with CAD (307 +/- 302 mU/ml, p = 0.0001). The only independent predictors of LVABS among women with anterior AMI were peak creatine kinase-MB value (p = 0.0001) and the presence of an antecedent stressful event (p = 0.001). LV systolic function at admission was similar between women with LVABS and those with CAD (echocardiographic ejection fraction 35.6 +/- 8.4% vs 35.5 +/- 8.0%, p = 0.944) but was significantly different at discharge (ejection fraction 50.1 +/- 9.6% vs 45.2 +/- 13.5%, p = 0.021). Moreover, at 6-month follow-up, women with LVABS showed a better survival rate (97% vs 86%, p = 0.055) and freedom from major cardiac events (death, reinfarction, or rehospitalization 92% vs 69%, p = 0.001) than women with CAD. In conclusion, few women presenting with clinical features of anterior AMI have LVABS. Despite a favorable outcome, LVABS should be considered in the differential diagnosis of women with chest pain and ST-segment elevation in the precordial leads. Peak creatine kinase-MB value and the presence of an antecedent stressful event are strong predictors of LVABS in women with anterior AMI.