A sneak peek on Takotsubo Syndrome

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION Takotsubo syndrome (TS) is characterized by transient wall motion abnormality of the left ventricle, which may happen in response to different triggers. AIM To characterize the population with confirmed diagnosis of TS. METHODS We analysed retrospectively 129 patients (pts) admitted in our center from 2010 to 2018 with this presumptive diagnosis. 29pts were excluded because TS wasn´t confirmed. For each pt we evaluate clinical characteristics, exams results, inhospital complications and long-term outcomes (minimum FUP of 1 year). RESULTS The average age was 66 years and 89% were females. Regarding the cardiovascular (Cv) risk factors, 78% had hypertension, 53% dyslipidemia and 19% Diabetes mellitus. In relation to noncardiovascular comorbidities it’s important to point out that 32% had psychiatric disorders. The trigger was emotional in 37%, physical in 18%, and unidentifiable in 45%. Concerning the clinical presentation 72% had Killip(K) 1 and 13% K≥3 at admission. The initial electrocardiogram had ST-elevation in 37%, T wave inversion in 64% and a mean QTc interval of 470ms. The mean ejection fraction (EF) by echocardiogram was 37%, with apical ballooning in 83% and at least moderate mitral regurgitation (MR) in 11%. Only 16% had intraventricular pressure gradient. Coronarography revealed absence of obstructive coronary disease in 71% of pts. In addition, 51% of pts underwent cardiac magnetic resonance (CMR), which had an increase usage since 2013. The mean time until the CMR was 14 days, which may explain why only 14% had segmental kinetic changes. It’s noteworthy that the mean peak NTproBNP/troponin I ratio was 1,4 ± 2,9. We compared the ratio in TS with EF < 40% with the one obtained in a cohort of ST-elevation myocardial infarction (MI) with EF < 40% and found statistically difference (1,7 ± 3,8vs0,01 ± 0,03; p < 0,001). Considering inhospital complications, 6% had intracardiac thrombus, 2% acute severe MR, 2% ventricular dysrhythmia and 2% died. During the FUP, 2% had recurrence, 4% had acute heart failure hospitalizations an 17% died. CONCLUSION Despite increased awareness TS is still poorly recognized. Lack of non-invasive tools for reliable diagnosis obliged the use of coronarography. It’s noteworthy that the peak NTproBNP/troponin I ratio may help to differentiate TS from MI and the use of CMR should be encouraged to exclude other causes. Although considered a benign condition, significant in-hospital mobility and 2% mortality was observed.

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Midventricular takotsubo syndrome: different dyskinesia location leading to a different electrocardiogram?

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.123 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

M Padilla Lopez ◽

A Duran Cambra ◽

M Vidal Burdeus ◽

L Rodriguez Sotelo ◽

J Sanchez Vega ◽

...

Keyword(s):

Acute Phase ◽

Clinical Symptoms ◽

Takotsubo Syndrome ◽

St Segment Elevation ◽

Funding Sources ◽

Wave Inversion ◽

St Segment ◽

Electrocardiogram Ecg ◽

Study Inclusion

Abstract Funding Acknowledgements Type of funding sources: None. Background Takotsubo syndrome (TKS) is characterized by the appearance of apical reversible dyskinesia in its typical form. Electrocardiogram (ECG) in the acute phase (<12 from symptom onset) generally shows anterior ST segment elevation. Nonetheless, other atypical forms of TKS have been described depending on the location of the dyskinetic segments, such as, mid-ventricular, basal and focal forms. Considering the different segments involved in these atypical forms, it seems reasonable to consider that ST changes in acute phase ECG could be different. Purpose To compare ECG in the acute phase of typical TKS versus mid-ventricular TKS, as it was the more frequent form of atypical TKS in our registry. Methods Patients included in the prospective TKS registry of our center according to the Mayo Clinic diagnostic criteria, with the first ECG performed less than 12 hours from the symptoms onset were reviewed. All cardiac left ventriculographies were reviewed to ensure a correct classification of the different types of TKS. Results A total of 297 patients were included in our local registry. 80 patients met our study inclusion criteria. 56 ECGs of typical apical TKS were compared to 24 ECGs of atypical midventricular TKS. There were no differences between the baseline characteristics in both groups, except for mid-ventricular TKS, that was more frequently triggered by physical stressor. Regarding the ECG analysis, the main difference found in our serie was related to ST-segment deviation (Table 1). While ST-segment elevation was more common in typical TKS than in atypical TKS (73% vs 50%), ST-segment depression (generally in inferior leads) was observed in 54% of patients with atypical TKS and in no patient with typical TKS (figure 1). Conclusion The different location of dyskinesia between typical TKS and mid-ventricular TKS is associated to significant differences in the ECG obtained in the first hours after the onset of the clinical symptoms. The presence of ST-segment depression is highly suggestive of mid-ventricular TKS. ECG characteristicsTypical (n = 56)Midventricular (n = 24)pSTe > 1mm, no (%)41 (73)12 (50)0,044STd >0,5 mm, no (%)013 (54)< 0,001T wave inversion, no (%)12 (21)4 (17)0,626Q wave, no (%)22 ( 39)12 (50)0,374cQT, mean (SD)445 (54)438 (37)0,578QRS low voltages*, n (%)9 ( 16)1 (4)0,328STe ST-segment elevation, STd: ST-segment depression, cQT: corrected QT interval *Voltages <5mm in all limb leads or <10mm in all precordial leads Abstract Figure. 12-lead ECG and left ventriculography

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Computational modeling of Takotsubo cardiomyopathy: effect of spatially varying β-adrenergic stimulation in the rat left ventricle

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.00443.2014 ◽

2014 ◽

Vol 307 (10) ◽

pp. H1487-H1496 ◽

Cited By ~ 14

Author(s):

Sander Land ◽

Steven A. Niederer ◽

William E. Louch ◽

Åsmund T. Røe ◽

Jan Magnus Aronsen ◽

...

Keyword(s):

Left Ventricle ◽

Takotsubo Cardiomyopathy ◽

Troponin I ◽

Contractile Function ◽

Single Cells ◽

Apical Ballooning ◽

Calcium Sensitivity ◽

Takotsubo Syndrome ◽

Adrenergic Stimulation ◽

Inotropic Effects

In Takotsubo cardiomyopathy, the left ventricle shows apical ballooning combined with basal hypercontractility. Both clinical observations in humans and recent experimental work on isolated rat ventricular myocytes suggest the dominant mechanisms of this syndrome are related to acute catecholamine overload. However, relating observed differences in single cells to the capacity of such alterations to result in the extreme changes in ventricular shape seen in Takotsubo syndrome is difficult. By using a computational model of the rat left ventricle, we investigate which mechanisms can give rise to the typical shape of the ventricle observed in this syndrome. Three potential dominant mechanisms related to effects of β-adrenergic stimulation were considered: apical-basal variation of calcium transients due to differences in L-type and sarco(endo)plasmic reticulum Ca2+-ATPase activation, apical-basal variation of calcium sensitivity due to differences in troponin I phosphorylation, and apical-basal variation in maximal active tension due to, e.g., the negative inotropic effects of p38 MAPK. Furthermore, we investigated the interaction of these spatial variations in the presence of a failing Frank-Starling mechanism. We conclude that a large portion of the apex needs to be affected by severe changes in calcium regulation or contractile function to result in apical ballooning, and smooth linear variation from apex to base is unlikely to result in the typical ventricular shape observed in this syndrome. A failing Frank-Starling mechanism significantly increases apical ballooning at end systole and may be an important additional factor underpinning Takotsubo syndrome.

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Value of Cardiac Biomarkers in the Early Diagnosis of Takotsubo Syndrome

Journal of Clinical Medicine ◽

10.3390/jcm9092985 ◽

2020 ◽

Vol 9 (9) ◽

pp. 2985

Author(s):

Charlotte Dagrenat ◽

Jean Jacques Von Hunolstein ◽

Kensuke Matsushita ◽

Lucie Thebaud ◽

Stéphane Greciano ◽

...

Keyword(s):

Psychiatric Disorders ◽

Troponin I ◽

Early Stage ◽

Cardiac Biomarkers ◽

Takotsubo Syndrome ◽

Gender History ◽

Cardiac Biomarker ◽

History Of ◽

St Elevation ◽

Bedside Diagnosis

Background: Bedside diagnosis between Takotsubo syndrome (TTS) and ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction remains challenging. We sought to determine a cardiac biomarker profile to enable their early distinction. Methods: 1100 patients (TTS n = 314, STEMI n = 452, NSTEMI n = 334) were enrolled in two centers. Baseline clinical and biological characteristics were compared between groups. Results: At admission, cut-off values of BNP (B-type natriuretic peptide)/TnI (Troponin I) ratio of 54 and 329 distinguished respectively STEMI from NSTEMI, and NSTEMI from TTS. Best differentiation was obtained by the use of BNP/TnI ratio at peak (cut-of values of 6 and 115 discriminated respectively STEMI from NSTEMI, and NSTEMI from TTS). We developed a score including five parameters (age, gender, history of psychiatric disorders, LVEF, and BNP/TnI ratio at admission) enabling good distinction between TTS and STEMI (77% specificity and 92% sensitivity, AUC 0.93). For the distinction between TTS and NSTEMI, a four variables score (gender, history of psychiatric disorders, LVEF, and BNP at admission) achieved a good diagnostic performance (89% sensitivity, 85% specificity, AUC 0.94). Conclusion: A distinctive cardiac biomarker profile enables at an early stage a differentiation between TTS and ACS. A four (NSTEMI) or five variables score (STEMI) permitted a better discrimination.

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Takotsubo syndrome in elderly woman: The diagnosis by transthoracic echocardiography

SAGE Open Medical Case Reports ◽

10.1177/2050313x19878928 ◽

2019 ◽

Vol 7 ◽

pp. 2050313X1987892

Author(s):

Inggita Hanung Sulistya ◽

Anggoro Budi Hartopo ◽

Lucia Kris Dinarti ◽

Budi Yuli Setianto

Keyword(s):

Acute Coronary Syndrome ◽

Left Ventricle ◽

Transthoracic Echocardiography ◽

Troponin I ◽

Acute Chest Pain ◽

Apical Ballooning ◽

Transient Condition ◽

Takotsubo Syndrome ◽

Coronary Syndrome ◽

Concentric Hypertrophy

Takotsubo syndrome has increasingly been recognized in the differential diagnosis of patients presenting with acute chest pain. Those affected are typically older women suffering after an emotional or physical stress. Normally it is a transient condition but complications including death have been reported. We reported a case of takotsubo syndrome who was initially diagnosed as acute coronary syndrome. The patient presented with typical angina, ST-T segment changes, and elevated high sensitive–troponin I. Coronary angiography showed normal coronary arteries. Transthoracic echocardiography revealed mild left atrial dilatation and left ventricle concentric hypertrophy, reduced left ventricle ejection fraction with circumferential hypokinetic, apical ballooning, systolic anterior motion, left ventricle outflow tract obstruction, and sigmoid septum hypertrophy. One month later, patient recovered and transthoracic echocardiography revealed improved heart anatomy and function. To differentiate takotsubo syndrome with other conditions, especially acute coronary syndrome, is crucial. Their clinical presentations are similar but the managements are different. The transthoracic echocardiography holds an important role in supporting the diagnosis of takotsubo syndrome.

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Takotsubo syndrome in bipolar affective disorder with alcohol withdrawal syndrome

BMJ Case Reports ◽

10.1136/bcr-2020-236070 ◽

2020 ◽

Vol 13 (10) ◽

pp. e236070

Author(s):

Deshwinder Singh Sidhu ◽

Richard Farrelly ◽

John Lally

Keyword(s):

Affective Disorder ◽

Troponin I ◽

Epigastric Pain ◽

Bipolar Affective Disorder ◽

Alcohol Withdrawal Syndrome ◽

Takotsubo Syndrome ◽

History Of ◽

Alcohol Dependence Syndrome ◽

Background History ◽

St Elevation

A 40-year-old woman presented to the emergency department with epigastric pain and agitation. She recently separated from her husband and was consuming 30 units of alcohol daily for 5 days. She had a history of bipolar affective disorder, borderline personality disorder and alcohol dependence syndrome. Investigations revealed the following: elevated troponin I levels, ST elevation, early Q waves and prolonged QTc. Emergency angiogram confirmed Takotsubo’s appearance. Medications with QTc prolongation propensity were held. A multidisciplinary apporach was required. She was discharged 10 days later when medically stabilised. It was later discovered that she died unexpectedly the following month. Takotsubo syndrome is a rare but unique cause of cardiac failure. This case highlights the need to consider the differential of Takotsubo syndrome in people presenting with possible acute ischaemic events, particularly in those with a history of combined emotional and physical stressors and a background history of mood disorder.

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P256 Takotsubo syndrome early after treatment due to non cardiotoxic chemotheraphy agents

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.117 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Cited By ~ 1

Author(s):

B Ozbay ◽

E Gurses ◽

H Kemal ◽

E Simsek ◽

H Kultursay

Keyword(s):

Coronary Angiography ◽

Left Ventricle ◽

Troponin T ◽

Epigastric Pain ◽

Apical Ballooning ◽

Prior History ◽

Takotsubo Syndrome ◽

Coronary Syndrome ◽

T Wave ◽

Wave Inversion

Abstract Physicians have encountered cardiotoxicity in different situations. The most known scenario is heart failure after especially anthracycline treatment. In this case, immediately after chemotherapy typical Takotsubo syndrome developed and was diagnosed with normal coronary angiography with apical ballooning movement in ventriculography. Acute cardiotoxicity may depend on different pathogenesis than ordinary toxicity mechanism. Case report A 65 years old female attended emergency department with epigastric pain after chemotherapy. She had vinorelbine and gemcitabine treatment for malignant urotelial renal carcinoma. The patient was consulted with cardiology department, because of progressive high troponin T levels. She had no prior history except urotelial carsinoma for one year and hypertension for seven years. Her prior chemotherapy protocols included carboplatine and docetaxel. She did not describe typical angina pectoris or shortness of breath. Electrocardiography (ECG) at admission had symmetrical T wave inversion on precordial derivations (figure 1). Echocardiography (echo) showed typical apical ballooning of the left ventricle (figure 2 and 3). We do not know the patient’s prior cardiac performance and acute coronary syndrome and Takotsubo syndrome were our preliminary diagnosis. Normal coronary arteries were seen on coronary angiography, ventriculography revealed apical ballooning movement of the left ventricle (Figure 4) and this supported our diagnosis as Takotsubo syndrome. She was already on valsartane 160 mg daily for hypertension and we included metoprolol 50 mg daily and enoxoparine 6000 IU s.c twice a day. For several days deep symmetrical T wave inversion persisted on ECG. After third day her ECG changings resolved (Figure 5) and echo images had recovered. The patient was discharged uneventfully and is followed. Abstract P256 figures

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The electrocardiographic ‘triangular QRS-ST-T waveform’ pattern: a marker of severe haemodynamic compromise in Takotsubo syndrome—a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa076 ◽

2020 ◽

Vol 4 (3) ◽

pp. 1-6

Author(s):

Tuukka Joki ◽

Kjell Nikus ◽

Jari Laukkanen

Keyword(s):

Systolic Dysfunction ◽

Apical Ballooning ◽

Left Ventricular ◽

Lv Function ◽

Takotsubo Syndrome ◽

St Elevation ◽

Electrocardiogram Ecg ◽

Waveform Pattern ◽

Lambda Wave

Abstract Background Takotsubo cardiomyopathy is characterized by transient regional systolic dysfunction of the left ventricle, mimicking myocardial infarction. Although systolic left ventricular (LV) function normalizes in most cases, the outcome is not always favourable. Recently, a rare electrocardiogram (ECG) finding, lambda wave ST elevation or ‘triangular QRS-ST-T waveform’, was suggested as a possible marker of poor outcome in Takotsubo patients Case summary After a brief episode of chest pain and shortness of breath, a 67-year-old woman developed cardiogenic shock. Her resting ECG showed widespread ST elevations, which soon evolved into a pattern of triangular QRS-ST-T waveforms in the inferior leads and V3–V6. Emergent coronary angiography was normal. The ejection fraction was 20% with apical ballooning and an LV thrombus. At 1-month follow-up, the patient was asymptomatic and the ECG showed only T-wave inversions. Discussion The triangular QRS-ST-T waveform ECG pattern has recently been introduced as a high-risk marker in the Takotsubo syndrome.

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Evaluation of Ventricular Repolarization Parameters in Patients Admitted to Emergency Department with Electrical Injury

10.22514/sv.2020.16.0076 ◽

2020 ◽

Keyword(s):

Ventricular Arrhythmias ◽

Troponin I ◽

Ventricular Repolarization ◽

Control Group ◽

Qtc Interval ◽

Elevated Troponin ◽

Surface Ecg ◽

Healthy Control ◽

The Mean ◽

Electrocardiogram Ecg

Objective: Prolonged T-peak to T-end (Tp-e), a ventricular repolarization parameter, has been related with ventricular arrhythmias (VAs). Novel electrocardiogram (ECG) parameters of ventricular repolarization have received considerable attention recently. In this study, we sought to investigate ventricular repolarization indexes such as the Tp-e and corrected Tp-e (Tp-ec) intervals, Tp-e/QT, Tp-e/QTc, and Tp-ec/QT ratios in patients with electrical injuries (EIs). Methods: Thirty-six patients diagnosed with EIs and 35 age- and sex-matched healthy control patients were included. Admission ECGs of the EI patients were compared with those of the healthy controls. QT and QTc intervals were measured, and the Tp-e and Tp-ec intervals, Tp-e/QT, Tp-ec/QT, and Tp-e/QTc ratios were then calculated from a 12-lead surface ECG. Results: The QT, Tp-e, Tp-e/QT, Tp-e/QTc, Tp-ec/QT were not significantly different between the control group and the EI group (p > 0.05). However, the mean QTc interval was significantly higher in the EI group compared to the control group (412.81 ± 25.46 vs 396.31 ± 26.47 ms; p:0.009). Furthermore, the Tp-ec and Tp-ec/QT of the EI subgroup with elevated troponin levels significantly differed from those of the EI patients with normal troponin levels (p:0.033 and p:0.016, respectively). Conclusions: This retrospective study indicated that patients with EIs tend to have a prolonged QTc interval. Additionally, Tp-ec and Tp-ec/QT, which reportedly designate the tendency for VAs, were significantly higher in the EI patients with elevated troponin I levels than the EI patients with normal troponin levels, suggesting that patients with myocardial injury may be prone to VAs.

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Abstract 15688: Electrocardiographic Patterns Differentiating "Apical Ballooning" From Anterior Myocardial Infarction

Circulation ◽

10.1161/circ.130.suppl_2.15688 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Birke Schneider ◽

Kay Peters ◽

Udo Desch ◽

Jürgen Stein

Keyword(s):

Myocardial Infarction ◽

Adverse Events ◽

Apical Ballooning ◽

Qtc Interval ◽

Anterior Myocardial Infarction ◽

St Segment Elevation ◽

T Wave ◽

Wave Inversion ◽

St Segment

Introduction: Left ventricular apical ballooning (AB) mimics anterior myocardial infarction (AMI). This study assessed if the ECG can differentiate between these two syndromes with a similar clinical presentation. Methods: Among 2086 patients (pts) with an ACS, 33 (1.6%) with AB were identified (29 f, 4 m, median age 77 years) and compared to 28 consecutive age and sex matched AMI pts undergoing PCI of the LAD with similar findings on LV angiography. Results: AB pts arrived at the hospital later after symptom onset (median 21 vs 5 hours; p<0.001). On the admission ECG, the number of leads with ST-segment elevation (4 [3-6] vs 5 [5-7], p=0.005) and the magnitude of ST-segment elevation (0.7 [0.5-0.9] vs 0.9 [0.7-1.5] mV, p=0.002) were greater in AMI. Reciprocal ST-segment depression was similar (27% vs 54%, p=ns). A positive T wave in aVR was more frequent in AB (49% vs 7%, p<0.001). During follow-up, AB pts had more leads with T-wave inversion (8 [8-9] vs 6 [5-8], p<0.001) and a larger magnitude of T-wave inversion (2.9 [2.2-4.6] vs 1.4 [0.9-2.3] mV, p<0.001). T-wave inversion was similar in I, aVL and V2-V5. AB pts, however, showed negative T-waves also in lead II (74% vs 22%, p<0.001), III (34% vs 4%, p=0.004), aVF (51% vs 11%, p=0.001) and a positive T wave in aVR (100% vs 70%, p=0.005). The QTc interval was longer in AB (515 [482-543] vs 458 [435-484] ms, p<0.001). An abnormal Q wave on admission was more frequent in AMI (21% vs 79%, p<0.001) and persisted but was absent in AB at discharge (0% vs 61%, p<0.001). Ventricular tachycardia was similar (2% vs 14%, p=ns) but atrial fibrillation occurred only in AB (21% vs 0%, p=0.013). The ECG normalized in all AB but in only 1 AMI pt (p<0.001). Overall, despite a similar ejection fraction (54±15 vs 55±13 %) and lower troponin I values (7.5±6.9 vs 238±221 ng/ml, p<0.001), AB pts developed significantly more adverse events compared to AMI pts (52% vs 18%, p<0.008). Conclusion: ECG patterns in AB are significantly different from those in AMI. On admission, the extent of ST-segment elevation and the number of Q waves are greater in AMI. During follow-up, no Q wave, a longer QTc interval, a greater extent of T-wave inversion and a positive T wave in aVR are typical findings in AB. Adverse events are more frequent in AB than in AMI.

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533 Uncommon ECG presentation in Tako-tsubo syndrome

European Heart Journal Supplements ◽

10.1093/eurheartj/suab140 ◽

2021 ◽

Vol 23 (Supplement_G) ◽

Author(s):

Lorenzo Acone ◽

Alonge Stefanoa ◽

Evelina Toscano ◽

Andrea Mortara

Keyword(s):

Coronary Angiography ◽

Troponin I ◽

Systolic Function ◽

Apical Ballooning ◽

St Depression ◽

St Segment ◽

St Elevation ◽

Diagnostic Work ◽

Work Up ◽

Diagnostic Work Up

Abstract Aims We present the case of an 80-year-old woman without prior cardiovascular history, recent instrumental diagnosis of peritoneal carcinomatosis and ongoing oncologic diagnostic work up. Methods and results The patient was admitted to our ED for acute-onset worsening dyspnoea. On first clinical evaluation, she denied typical angina, remarkable clinical features were dyspnoea, tachycardia and hypotension. Admission ECG showed sinus rhythm with posterior and inferior ST elevation (leads DII, aVF, V5, V6) with reciprocal ST segment depression in leads V1–V2. Echocardiography confirmed infero-postero-lateral akinesia determining moderate reduction of LVEF (35–40%), normal aortic root, no pericardial effusion. Laboratory tests revealed normal WBC count, mild anaemia (HB 10.7 g/dl), normal renal function, elevated C-reactive protein (139 mg/l, n.v. < 8). Cardiac troponin I (cTnI) was normal on admission, with significant delta on second determination (0.012 > 2.5 ng/ml, nv < 0.023). ST elevation persisted after BP normalization and hypoxia treatment; so, taken into account the increased procedural risk due to patient’s age and comorbidities, however we decided to perform urgent coronary angiography. Surprisingly, coronary angiography revealed absence of any significant stenosis, with TIMI 3 flow in any coronary segment. The patient was then admitted to the ICU with diagnosis of MINOCA. The next day ECG revealed normalization of ST segment and Q wave in V2–V3. On day 2 new ECG showed new ventricular repolarization abnormalities with T wave inversion in precordial leads. Peak hs-cTnI was >15 000 ng/l. Repeat echocardiography on day 2 reported complete akinesia of all the apical segments of the LV with normo-hyperkinesia of the mid-basal segments (apical ballooning pattern) and severely depressed systolic function (FE 32–35%). During the following days patient’s symptoms improved, with rapid weaning from oxygen therapy and stable haemodynamic parameters. After 10 days the patient repeated echocardiography, which revealed improvement of global LVEF and persisting mild apical hypokinesia, suggesting the diagnostic hypothesis of Tako-Tsubo Syndrome (TTS) or TTS-phenocopy (unfortunately cardiac MRI was not performed). The patient was therefore transferred to oncology department to complete the diagnostic work-up; primary mammary neoplasia was identified, moreover associated with metastasis in the liver and the brain. Unfortunately, the patient died a month later due to non-cardiac causes. This is the case report of an uncommon MINOCA, which presented mimicking inferolateral acute STEMI, but subsequent ECG and echocardiographic evolution showed the more typical TTS pattern, with apical ballooning on echo and deep negative T waves in anterior leads. Conclusions The prevalence of MINOCA is estimated to be 6% to 8% among patients diagnosed with MI, especially women, however it is more common in patients with NSTEMI compared with STEMI; moreover in cases of TTS presenting with ST elevation, usually the elevation is found in anterior leads without reciprocal ST depression; in this patient instead ST elevation was inferolateral with reciprocal anterior ST depression. Absence of obstructive CAD and clinical/echocardiographic evolution allowed us to confirm the diagnosis of MINOCA/TTS.

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