Background: Takotsubo cardiomyopathy usually presents with acute reversible left ventricular apical hypokinesia and apical ballooning with basal hyperdynamic function. We describe an underreported case of Takotsubo cardiomyopathy (TCM), misinterpreted as apical hypertrophic cardiomyopathy (HCM) due to transient apical oedema in the recovery phase of the condition.
Case summary: A 74-year-old Caucasian woman, presented to the emergency department complaining of retrosternal chest pain following, emotional stress. Her electrocardiogram (ECG) demonstrated poor R-wave progression in the right precordial leads raising the possibility of an anterior non-ST elevation myocardial infarction. High sensitivity troponin was elevated at 2232 ng/L, echocardiography demonstrating apical ballooning and left ventricular ejection fraction of 45%. Computed tomography coronary angiography revealed unobstructive coronary arteries. Cardiac magnetic resonance imaging (cMRI) demonstrated morphological features consistent with apical HCM. However, subsequent cMRI examination, illustrated resolution of the hypertrophic segments, with T1 parametric mapping and extracellular volume (ECV) favouring TCM over apical HCM.
Discussion: Following emotional stress, takotsubo cardiomyopathy is understood caused by various mechanisms: catecholamine surge, inflammation, or transient ischaemia event leading to dysregulated cellular mechanisms. This results in myocardial oedema and increased wall stiffness leading to non-type 1 coronary plaque event-related regional wall motion abnormalities.In this instance, the initial two cMRI studies reported morphological features consistent with apical HCM, however, a subsequent examination demonstrated resolution of these features. The key to delineating these distinct pathologies lies in myocardial T1 times that exceeded what is normally observed in HCM, the absence of late gadolinium enhancement and ECV values which favour takotsubo cardiomyopathy.
Keywords: Apical ballooning Syndrome; Apical hypertrophic cardiomyopathy; Cardiac magnetic resonance Imaging; Case report; Parametric mapping; Takotsubo cardiomyopathy; Transient apical wall thickening.
© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.