title: Regional wall motion abnormality in apical ballooning syndrome (Takotsubo/stress cardiomyopathy): importance of biplane left ventriculography for differentiating from spontaneously aborted anterior myocardial infarction.
abstract: Understanding the precise distribution of the regional wall motion abnormality (RWMA) in apical ballooning syndrome (ABS) is important because the cardiomyopathy can mimic an acute anterior ST-elevation myocardial infarction (STEMI). The aim of the study was to quantify the severity and distribution of RWMA in ABS, compare it to anterior STEMI, and correlate with clinical features. RWMA (normal = 1, hypokinetic = 2, akinetic = 3) was quantified from the biplane left ventriculogram using a nine-segment model in 95 ABS and 17 anterior STEMI patients at the time of their presentation. Regional wall motion score index (RWMSI) was higher in ABS [2.1 (1.9, 2.1)] compared to anterior STEMI [2.0 (1.8, 2.0)], P = 0.024]. The region that most clearly differentiated ABS from anterior STEMI was the posterolateral segment (sensitivity 81% and specificity 100%) which was hypocontractile in 81% of ABS, but none of the STEMI patients (P < 0.001). RWMSI in ABS had a modest positive correlation with the troponin T levels (r = 0.23, P = 0.029). Patients with ABS with ST-segment elevation had the highest RWMSI [2.1(2.0, 2.2)], while those with non specific changes had the lowest [1.9 (1.8, 2.1)] (P = 0.007). In conclusion, patients with ABS have greater and more diffuse RWMA compared to anterior STEMI. The presence of systolic dysfunction in the posterolateral segment in the left anterior oblique projection of the left ventriculogram most accurately distinguishes ABS from an anterior STEMI highlighting the utility of biplane angiography for this purpose. The severity of RWMA correlates with the extent of troponin release and ECG abnormality.
authors.affiliation: The Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: Sandeep M
authors.initials: SM
authors.lastname: Patel
authors.forename: Ryan J
authors.initials: RJ
authors.lastname: Lennon
authors.forename: Abhiram
authors.initials: A
authors.lastname: Prasad
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D056988:Anterior Wall Myocardial Infarction / Q000097:blood / Q000000981:diagnostic imaging*; D015415:Biomarkers / Q000097:blood; D052279:Creatine Kinase, MB Form / Q000097:blood; D003937:Diagnosis, Differential; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008875:Middle Aged; D008910:Minnesota; D009200:Myocardial Contraction; D020097:Natriuretic Peptide, Brain / Q000097:blood; D011237:Predictive Value of Tests; D011859:Radiography; D012189:Retrospective Studies; D012720:Severity of Illness Index; D054549:Takotsubo Cardiomyopathy / Q000097:blood / Q000000981:diagnostic imaging* / Q000503:physiopathology; D020107:Troponin T / Q000097:blood; D016277:Ventricular Function, Left
chemical_list: D015415:Biomarkers; D020107:Troponin T; D020097:Natriuretic Peptide, Brain; D052279:Creatine Kinase, MB Form