Differential diagnosis at admission between takotsubo cardiomyopathy and acute apical-anterior myocardial infarction in postmenopausal women

Background: Takotsubo cardiomyopathy (TTC) typically affects postmenopausal women and clinically presents with chest pain, ST-segment elevation, elevated cardiac enzymes and apical left ventricular (LV) wall motion abnormalities that mimic ‘apical-anterior’ acute myocardial infarction (AMI). This study assessed whether at-admission clinical evaluation helps in differential diagnosis between the two conditions. Methods: The study compared at-admission clinical, electrocardiographic (ECG) and echocardiographic findings of 31 women (median age 67 years, interquartile range (IQR) 62–76) with typical TTC and 30 women (median age 73 years, IQR 61–81) with apical-anterior AMI due to acute occlusion of the mid/distal left anterior descending coronary artery. Results: Women with TTC significantly more often showed PR-segment depression (62% versus 3%, p<0.001), J-waves (26% versus 3%, p=0.03), maximum ST-segment elevation ⩽2 mm (84% versus 37%, p<0.001) and ST-segment elevation in lead II (42% versus 10%, p=0.01) than those with AMI. At multivariate analysis, PR-segment depression (odds ratio (OR)=37.2, 95% confidence interval (CI)=3.4–424, p=0.002) and maximum ST-segment elevation ⩽2 mm (OR=11.1, 95% CI=1.7–99.4, p=0.01) remained the only independent predictors of TTC and the co-existence of both parameters excluded AMI with a 100% specificity. The two groups did not differ with regard to age, first troponin-I value, echocardiographic LV ejection fraction and distribution of hypo/akinetic LV segments. Conclusions: At-admission electrocardiogram (but no clinical, laboratory and echocardiographic features) allows differential diagnosis between TTC and apical-anterior AMI in postmenopausal women. The combination of PR-segment depression and mild (⩽2 mm) ST-segment elevation predicted TTC with greater accuracy than traditional parameters such as localisation of ST-segment elevation and reciprocal ST-segment depression.