title: Is it possible to differentiate between Takotsubo cardiomyopathy and acute anterior ST-elevation myocardial infarction?
abstract: BACKGROUND
  Several studies have investigated the ability of the twelve-lead electrocardiogram (ECG) to reliably distinguish Takotsubo cardiomyopathy (TC) from an acute anterior ST-segment elevation myocardial infarction (STEMI). In these studies, only ECG changes were required - ST-segment deviation and/or T-wave inversion - in TC whereas in acute anterior STEMI, ECGs had to meet STEMI criteria. In the majority of these studies, patients of both genders were used even though TC predominantly occurs in women. The aim of this study is to see whether TC can be distinguished from acute anterior STEMI in a predominantly female study population where all patients meet STEMI-criteria.
  
  
  METHODS
  Retrospective analysis of the ST-segment changes was done on the triage ECGs of 37 patients with TC (34 female) and was compared to the triage ECGs of 103 female patients with acute anterior STEMI. The latter group was divided into the following subgroups: 46 patients with proximal, 47 with mid and 10 with distal LAD occlusion. Three ST-segment based ECG features were investigated: (1) Existing criterion for differentiating anterior STEMI from TC: ST-segment depression >0.5mm in lead aVR+ST-segment elevation ≤1mm in lead V1, (2) frontal plane ST-vector and (3) mean amplitude of ST-segment deviation in each lead.
  
  
  RESULTS
  The existing ECG criterion was less accurate (76%) than in the original study (95%), with a large difference in sensitivity (26% vs. 91%). Only a frontal plane ST-vector of 60° could significantly distinguish TC from all acute anterior STEMI subgroups (p<0.01) with an overall diagnostic accuracy of 81%. The mean amplitude in inferior leads II and aVF was significantly higher for patients with TC compared to all patients with acute anterior STEMI (p<0.01 and p<0.05 respectively) and the mean amplitude in the precordial leads V1 and V2 was significantly lower compared to proximal and mid LAD occlusion (p<0.01).
  
  
  CONCLUSIONS
  Given the consequences of missing the diagnosis of an acute anterior STEMI the diagnostic accuracy of the ECG criteria investigated in this retrospective study were insufficient to reliably distinguish patients with TC from patients with an acute anterior STEMI. To definitely exclude the diagnosis of an acute anterior STEMI coronary angiography, which remains the gold standard, will need to be performed.
authors.affiliation: Department of Cardiology, Maastricht University Medical Centre, the Netherlands. Electronic address: fabienne_vervaat@live.nl.
authors.forename: Fabienne E
authors.initials: FE
authors.lastname: Vervaat
authors.affiliation: Department of Cardiology, Copenhagen University Hospital, Denmark; Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Denmark.
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Christensen
authors.affiliation: Department of Medical and Clinical Psychology, Center of Research on Psychology in Somatic Diseases, Tilburg University, the Netherlands.
authors.forename: Loes
authors.initials: L
authors.lastname: Smeijers
authors.affiliation: Department of Cardiology, Copenhagen University Hospital, Denmark.
authors.forename: Lene
authors.initials: L
authors.lastname: Holmvang
authors.affiliation: Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Denmark.
authors.forename: Philip
authors.initials: P
authors.lastname: Hasbak
authors.affiliation: Department of Cardiology, St. Elisabeth Hospital, Tilburg, the Netherlands.
authors.forename: Balázs M
authors.initials: BM
authors.lastname: Szabó
authors.affiliation: Department of Cardiology, TweeSteden Hospital, Tilburg, the Netherlands.
authors.forename: Jos W M G
authors.initials: JW
authors.lastname: Widdershoven
authors.affiliation: Department of Cardiology, Duke Clinical Research Institute, Durham, NC, USA.
authors.forename: Galen S
authors.initials: GS
authors.lastname: Wagner
authors.affiliation: Department of Cardiology, Copenhagen University Hospital, Denmark.
authors.forename: Lia E
authors.initials: LE
authors.lastname: Bang
authors.affiliation: Department of Cardiology, Maastricht University Medical Centre, the Netherlands.
authors.forename: Anton P M
authors.initials: AP
authors.lastname: Gorgels
mesh_terms: D000368:Aged; D000465:Algorithms; D003936:Diagnosis, Computer-Assisted / Q000379:methods*; D003937:Diagnosis, Differential; D004562:Electrocardiography / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis*; D015588:Observer Variation; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D054549:Takotsubo Cardiomyopathy / Q000175:diagnosis*; D014218:Triage / Q000379:methods*
keywords: Acute anterior myocardial infarction; Acute coronary syndrome; Takotsubo cardiomyopathy