Case Report: Differential Diagnosis Takotsubo and Acute Coronary Syndrome Gabriel Borges Bessa Abdallah Khachab, Paula Freitas Martins Burgos, Rubens Fraga Pinto, Marcello Romiti

Abstract

Introduction: Takotsubo Syndrome or Cardiomyopathy (CMT) is characterized by regional and transient systolic dysfunction of the left ventricle (LV). The need for differential diagnosis of chest pain, which can confuse, merge the clinical picture of acute coronary syndrome (ACS), in the absence of evidence of obstructive arterial disease (CAD) on coronary angiography. It affects 85% to 90% of women, especially in the postmenopausal period between the ages of 65 and 70. Methodology: This is a case report that aims to bring CMT as a differential of ACS in a young patient and discuss the particularities, in order to expand the knowledge of the case in question and thus, aiming to clarify the presentation of clinical health conditions for the population. Case Report: A.L.P.S, female, 38 years old, sexually active, with no history of arterial hypertension, smoking, lung disease and/or generalized anxiety disorder, admitted with typical precordialgia that started after emotional stress. Initially, the hypothesis of ACS was raised, and the COVID-19 test was performed upon the patient's arrival as per protocol (negative). There were no electrocardiographic (ECG) changes, but the enzymatic curve of myocardial necrosis markers was positive (MNM) and compatible. Echocardiogram showing signs of moderate diffuse hypokinesia, more pronounced in the apical segment of the septum and anterior wall. Magnetic Resonance Imaging (MRI) of the Heart showed significant left ventricular systolic dysfunction due to marked hypokinesia of all segments of the middle and apical portions and apex dyskinesia (segment 17). Coronary cine echocardiography (CATE) showed coronary arteries free of obstructive atheromatosis or acute rupture of atheromatous plaque; left ventriculography, presence of dyskinesia in the apical wall, severe hypokinesia of the anterior wall and normal contractile function in the other walls. The findings rule out the initial diagnosis and suggest MTC. According to reports at admission, the patient evolved with hemodynamic stability, improvement of chest pain and discharge for outpatient follow-up. According to data from the medical records, myocardial contractile function showed global and segmental improvement only after 6 months. Discussion: Initially, according to clinical reports, the hypothesis of non-ST-segment elevation myocardial infarction (NSTEMI) was raised. The absence of obstructive atheromatosis on CATE performed later ruled out the possibility of NSTEMI and reinforced MTC as the most likely etiology, since it is capable of mimicking ACS; but without coronary atherothrombotic obstruction. The hypothesis of CMT should be considered as a differential diagnosis of ACS, especially in women after severe emotional stress. The patient presented suggestive and characteristic findings on ECHO, cardiac MRI and ventriculography. The presence of hypokinesia of the apical and middle segment of the LV and severe hypokinesia in the anterior wall, giving a classic aspect of apical ballooning. The treatment was basically hemodynamic support, drugs from the heart failure protocol and control of complications. The clinical case reported according to the analyzed medical records presented characteristics compatible with CMT, from its clinical presentation on admission to the evidence of LV wall abnormalities on the ventriculography study and the absence of signs of obstructive pathology on the coronary angiography study, which corroborates the pattern described in the literature of this pathology. Results: The present case report allowed a theoretical deepening on the subject and the dissemination in the medical and academic community of the peculiarities of this syndrome, mainly as a differential diagnosis. Conclusion: The similarity between the clinical presentation of Takotsubo cardiomyopathy and ACS highlights the relevance of CMT as a differential diagnosis of chest pain in women with typical triggers. Therefore, it is necessary to understand its epidemiological, clinical and radiological aspects.