649 Clinicians miss diagnosis: it wasn’t a tako-tsubo syndrome, nowadays it is a recurrent tako-tsubo syndrome

Aims Tako-Tsubo syndrome is an usual form of acute cardiomyopathy characterized by reversible left ventricle apical ballooning which occurs in the absence of significant coronary artery disease. Rarely an increase in catecholamines due to pheochromocytoma could lead to Tako-Tsubo syndrome. Here we report a clinical case of undetected pheochromocytoma which led to Tako-Tsubo syndrome in an adult female patient. Methods and results A 60 years old female presented at our emergency department with chest pain, increase in cardiac troponin levels and hypo-akinesia of the apical segments at the echocardiography. She was admitted with acute coronary syndrome suspicious. He had history of acute coronary syndrome with non-obstructive coronary arteries (MINOCA) in the 2017. Coronary angiography performed at 24 h from admission, again showed non-obstructive coronary disease, whereby we reviewed the previous MINOCA diagnosis into recurrence Tako-Tsubo syndrome diagnosis. During hospitalization she presented parossistic sinus tachycardia refractory to beta-blocker and ivabradine combined therapy. Cardiac magnetic resonance was performed and confirmed Tako-Tsubo syndrome, furthermore showed a surrenalic mass. Contrast-enhanced abdomen computed tomography and high levels of metanephrines suggested pheochromocytoma diagnosis. One month later she underwent left surrenectomy surgery. Histological examination confirmed pheochromocytoma. The last echocardiography didn’t show kinesia abnormalities with normal left ventricular function. Conclusions Our case illustrates the importance of understanding the correlation between Tako-tsubo syndrome and pheochromocytoma, especially in patients with increased activity of the sympathetic nervous system. Until recently, according to Tako-Tsubo syndrome Mayo Clinic criteria, our patient wouldn’t had receive a Tako-Tsubo syndrome diagnosis because pheochromocytoma was an exclusion criteria. Since 2018, Inter-TAK criteria replaced Mayo Clinic criteria including Tako-Tsubo syndrome expression of pheochromocytoma. Referring to our annoying title we always have to consider Tako-Tsubo syndrome into MINOCA differential diagnosis.