A 69-year-old woman with extended negative T wave.

Clinical Introduction

A 69-year-old woman with hypertension and dyslipidemia developed sudden onset of substernal chest pain at night and was admitted to our hospital the following day. A 12-lead and 18-lead ECG (Nihon Kohden, Japan) was done (figure 1A, B).

Figure 1

(A) Twelve-lead ECG. (B) Eighteen-lead ECG.

Reperfused anterior acute myocardial infarction

Takotsubo (stressed) cardiomyopathy

Pericarditis

Apical hypertrophic cardiomyopathy

Answer

B.Takotsubo (stress) cardiomyopathy

Extended negative T waves in a 12-lead ECG can be found in patients with acute myocardial infarction (AMI), Takotsubo cardiomyopathy, pericarditis and apical hypertrophic cardiomyopathy. In this patient, pericarditis was unlikely because there was no ST-segment elevation or PR-segment depression.1 Hypertrophic cardiomyopathy was also unlikely because of the prolonged QT interval2 and the lack of negative T waves with a strain pattern. However, it was challenging to differentiate an AMI from a Takotsubo cardiomyopathy with a 12-lead ECG.

Negative T wave locations in an 18-lead ECG provide the critical clue to differentiate between the two diseases.3 Negative T waves in precordial (V1, V2, V3, V4), inferior (especially in II) and posterolateral (V6, syn-V7, syn-V8 and syn-V9) leads reflect pathological conditions of the anterior, inferior and posterolateral myocardium the possibility of a Takotsubo cardiomyopathy should be strongly considered because simultaneous changes in these leads in an AMI is extremely rare.