The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Stress-Induced Cardiomyopathy and is brought to you by Jenna Pallansch, MD, Claire Lawson, NP, Shelby Hixson, PA, Emily Lipsitz, PA, Ashley Moore-Gibbs, DNP, Laszlo Littmann, MD, and John Symanski, MD.

1. John Symanski, MD, Laszlo Littmann, MD,
Jenna Pallansch, MD, Claire Lawson, NP, Shelby Hixson, PA,
Emily Lipsitz, PA, Ashley Moore Gibbs, DNP
Departments of Emergency Medicine and Internal Medicine
Sanger Heart & Vascular Institute
Carolinas Medical Center
Stress-Induced Cardiomyopathy
Michael A. Gibbs, MD, Lead Editor
Carolinas Medical Center Imaging Mastery Project

2. Visit Our Educational Website
www.EMGuidewire.com

3. Amyloid
Dilated
• Ischemic
• Peripartum
• Hypertensive
• Iron overload
Genetic
• Hypertrophic
• LV Noncompaction
• ARVC1
Inflammatory (Myocarditis)
• Viral
• Giant cell
• Eosinophilic
• Chagas
• COVID-19
Metabolic
• Diabetic
• Hypothyroid
• Acromegalic
• Cardiac Sarcoid
Stress-Induced (Takotsubo)
Tachycardia-Induced
Toxic
• Alcoholic
• Chemotherapy-induced
• Cocaine-induced
• Other drug related
1Arrhythmogenic Right Ventricular Cardiomyopathy
Classification Of Cardiomyopathies

4. Selected Embedded References:
Wittstein IS. Neurohormonal Features of Myocardial Stunning Due To Sudden Emotional Stress. New England
Journal of Medicine. 2006; 352:539-548.
Eitel I. Clinical Characteristics and Cardiac MR Findings In Stress Cardiomyopathy. Journal of the American
Medical Association. 2011; 306:277-286.
Amsterdam EA. 2104 AHA/ACC Guidelines for the Management of Patients With Non-ST Segment Acute
Coronary Syndrome. Circulation. 2014; DOI:10.1161/CIR.0000000000000134.
Templin C. Clinical Features And Outcomes Of Stress (Takotsubo) Cardiomyopathy. New England Journal of
Medicine. 2015; 373:10.
Lyon AR. Current state of knowledge on Takotsubo syndrome: a position statement from the task force on
Takotsubo syndrome of the Heart Failure Association of the European Society of Cardiology. European Journal
of Heart Failure. 2016; 18:8-27.
Pelliccia F. Pathophysiology of Takotsubo Cardiomyopathy. Circulation. 2017; 135:2426-2441.
de Chazal HM. Stress Cardiomyopathy Diagnosis and Treatment. JACC State-of-the-Art Review. Journal of the
American College of Cardiology. 2018; 72:1955-1971.

5. Stress-Induced (Takotsubo)
Cardiomyopathy
Cases Studies From Carolinas Medical Center

6. Case #1
44-Year-Old
Female
Develops
Chest Pain
After Getting
Into An
Argument
With Her
Best Friend.

8. Interpreted As Lateral STEMI An Taken For Emergent Cardiac Catheterization

9. Left Coronary System Right Coronary Artery
Normal Coronary Arteries

10. Diastole Systole
Left Ventriculogram

11. Apical Ballooning (*) With Hyperkinetic Basilar Segment (Arrows) Causing LVOT Obstruction
LVOT = Left Ventricular Outflow Tract
*
Diastole Systole

12. Normal ECG 6 Months Later (Asymptomatic)

13. Diastole Systole

14. Diastole Systole
Akinetic Apex
With
Ballooning
Hyperkinetic Basilar Segment
(Potential For LVOT Obstruction)

15. Case #2
66-Year-Old
Female With A
History Of
Substance
Abuse
Becomes
Upset After
Experiencing A
Relapse.

16. Diastole Systole
TTE (Apical 4-Chamber) Images

17. Diastole Systole
TTE (Apical 4-Chamber) Images
Akinetic Apex
With
Ballooning
Hyperkinetic
Basil Segment
And LVOT
Obstruction
Apex Apex

18. TTE (Apical 2-Chamber) Images
Diastole Systole

19. TTE (Apical 2-Chamber) Images
Akinetic Apex
With
Ballooning
Hyperkinetic
Basil Segment
And LVOT
Obstruction
ApexApex
Diastole Systole

20. TTE (Apical 3-Chamber) Images
Diastole Early Systole Late Systole
Note: Systolic Anterior Motion (SAM)
With Septal Contact
Apex

21. SAM-Associated Flow Acceleration In LVOT (Color Turbulence) And Mitral Regurgitation (Arrow)

22. Systolic Anterior Motion (SAM) Of The Posterior Leaflet Of The Mitral Valve
Encroaches The Ventricular Septum Causing LVOT Obstruction & Mitral Regurgitation.

23. Case #4: 75-Year-Old Female Presenting With Chest Pain And Dyspnea, Troponin 2208.
ECG #1: 15:00

24. Case #4: 75-Year-Old Female Presenting With Chest Pain And Dyspnea, Troponin 2208.
ECG #2: 17:45

25. Case #4: 75-Year-Old Female Presenting With Chest Pain And Dyspnea, Troponin 2208.
ECG #2: 17:45
Biphasic Precordial T Waves

26. Emergency Department Point-Of-Care Echocardiogram Apical 4 View

27. Emergency Department Point-Of-Care Echocardiogram Apical 4 View
Akinetic Apex
With
Ballooning
Formal Echocardiogram: Ejection Fraction 25%
Apex

28. Definition
First described in Japan in 1990 as Takotsubo Syndrome, it is also known
as stress-induced cardiomyopathy, broken heart syndrome, apical
ballooning syndrome, and acute reversible LV dysfunction.

29. The Most Widely Used Diagnostic Criteria Are Those From The
European Society Of Cardiology

30. Pathophysiology

31. Pathophysiology

38. Complications
• Acute heart failure
• Torsade de pointes VT related to QT prolongation
• Left ventricular outflow tract obstruction (LVOTO)
• Mitral regurgitations (MR)
• Both LVOTO and MR may lead to cardiogenic shock
• Apical akinesis increases the risk of thromboembolism
• Myocardial rupture (rare)

39. Epidemiology
• Stress cardiomyopathy occurs predominantly in postmenopausal women.
• Data from three registry studies:
1Templin C.
2Schneider B.
3Citro R.
New Engl J Med 2015.
Int J Cardiol 2013.
J Am Geriatr Soc 2012.
% Female Mean Age
N=1,7501 90% 67 years
N=3242 91% 68 years
N=1903 92% 66 years

40. From The Original 2001 Japanese Case Series [n=71]
Tsuchihaski K . Journal of the American College of Cardiology. 2001; 38:11-18.
Female 84%
Median age 67 ± 13 years
Associated acute precipitants:
 Medical event
 Emotional event
43%
27%
In-hospital complications:
 Pulmonary edema
 VT/VF
 Cardiogenic shock
22%
9%
15%

41. Emotional Triggers1
• Death of a loved one
• Tragic news
• Assault, violence, robbery
• Natural disasters
• Sudden financial loss
• A sense of doom, danger, or
desperation
1Roughly 30% of cases have no identifiable trigger.
• Public speaking
• Court appearance
• Personal conflict
• Panic, fear, anxiety

42. Physical Triggers1
• Critical illness
• Acute injury
• Surgery
• Several pain
• Acute neurologic event
• Heart failure exacerbation
• Asthma exacerbation
• Pheochromocytoma crisis
• Hypertensive emergency
• Preeclampsia
• Cocaine, methamphetamine use
• Large dose of catecholamines,
e.g.: continuous albuterol
1Roughly 30% of cases have no identifiable trigger.

43. 19 Patients

44. 182 Patients

45. Clinical Manifestations
• The typical history patient with stress cardiomyopathy is a
postmenopausal women who presents with acute or subacute:
• The physical exam reveals a tachypneic, tachycardic patients with signs of
heart failure. A systolic ejection murmur (due to LVOTO and MR) is often
heard.
Chest Pain 75%
Shortness of Breath 50%
Dizziness 25%
Syncope 5-10%

46. ECG Hallmarks
On Presentation
• Most commonly (80%) the ECG
mimics acute anterior STEMI, but:
• Less prominent ST elevation
• Less reciprocal ST depression
• No abnormal Q waves
• ST depression in aVR is more
common than in STEMI
• Less commonly: diffuse ST
depression and/or T-wave
inversion
24-48 Hours Later
• Diffuse T-wave inversion in  6
leads; aVR and V1 are usually
spared
• Frequently giant negative T waves
• Markedly prolonged QT
• Occasionally: the spiked helmet
sign

47. ECG Hallmarks

48. 80-Year-Old Female: Prior ECG
QTc = 484 ms

49. I
II
III F
1
2
3
4
5
6
II
Requested by:
Comment:
Hospital Day #2 For Chest Pain
QTc = 570 ms

50. I
II
III F
1
2
3
4
5
6
II
Requested by:
Comment:
25 mm/s 10 mm/mV 0.16-150 HzE-Scribe DICOM Module 1.3.6 Atrium Health Mercy
Hospital Day #3 For Chest Pain
QTc = 586 ms

51. I
II
III F
1
2
3
4
5
6
II
I have personally reviewed the EKG tracing and my findings are listed above: FEDOR, JOHN M
MD 11/12/2020 11:54:03
Requested by:
Comment:
25 mm/s 10 mm/mV 0.16-150 HzE-Scribe DICOM Module 1.3.6 CMC
One Month Later: Asymptomatic
QTc = 461 ms

52. 65-Year-Old With Status Asthmaticus And Acute Chest Pain
ECG ON PRESENTATION: ST ELEVATION IN V2-V4
ECG 48 HRS LATER: LARGE GLOBAL TWI, LONG QT EMERGENT CATHETERIZATION:
NORMAL CORONARY ARTERIES
APICAL BALLOONING

53. See Appendix 1 At The End Of This Presentation:
“Stress-Induced Cardiomyopathy ECG Case Studies.”
Created by the master ECG educator, Dr. Laszlo Littmann.

54. Biomarkers
• Cardiac troponin T or I elevated in >90% of patients, although with
lower levels than a classic acute coronary syndrome (ACS)
• Cardiac natriuretic peptides (BNP and pro-BNP) are always elevated,
with higher levels correlating with the degree of wall motion
abnormality and usually greater than that seen with ACS
• Peak biomarker levels occur at 48 hours

55. Biomarkers

56. Diagnostic Imaging
Echocardiography
Classic pattern: circumferential LV akinesis involving the entire cardiac apex along with
adjacent basilar hypercontractility
Coronary Angiography
 The decision to proceed with a coronary angiogram should be made on an individual basis
 Elderly patients may have underlying CAD not causing acute ischemia (bystander disease)
 A ventriculogram is diagnostic of stress cardiomyopathy and particularly helpful for the
midventricular form that may be difficult to visualize with echocardiography
Coronary Computed Tomography Angiography
Used to exclude high-grade coronary culprit lesions in patients with limited acoustic windows
and contraindications to CMR
Cardiac Magnetic Resonance
 CMR allows visualization of myocardial edema, inflammation, and scarring with the use of
delayed gadolinium enhancement
 During the acute phase, T2-weighted CMR shows edema as high signal intensity

57. Cardiac MRI: Gadolinium Enhancement
• Gadolinium containing contrast is widely used in cardiac MRI to
assess the integrity of the myocardium
• Gadolinium is typically taken up and rapidly washed out from healthy
myocardial cells
• In the presence of disease (e.g.: acute and chronic ischemia, prior
infarct, myocarditis, cardiomyopathies) gadolinium remains in
abnormal cardiomyocytes, thus causing late phase enhancement
gadolinium enhancement (LGE) on T1 images

59. * = Pericardial Effusion; ➤ = Apical Akinesis

60. ➤ = Mid Left Ventricular Akinesis

61. ➤ = Basilar Akinesis

62. ➤ = Basilar Akinesis
* = Pleural Effusions; ➤ = Apical Akinesis ➤ = RV Apex Akinesis

64. 2014 ACC/AHA Non-STEMI Guidelines

66. STRESS-INDUCED CARDIOMYOPATHY
ECG CASE STUDIES
Dr. Laszlo Littmann, MD
Department of Internal Medicine
Carolinas Medical Center
November 2020
APPENDIX 1

67. ECG Hallmarks
On Presentation
• Most commonly (80%) the ECG
mimics acute anterior STEMI, but:
• Less prominent ST elevation
• Less reciprocal ST depression
• No abnormal Q waves
• ST depression in aVR is more
common than in STEMI
• Less commonly: diffuse ST
depression and/or T-wave
inversion
24-48 Hours Later
• Diffuse T-wave inversion in  6
leads; aVR and V1 are usually
spared
• Frequently giant negative T waves
• Markedly prolonged QT
• Occasionally: the spiked helmet
sign

68. 65-Year-Old With Status Asthmaticus And Acute Chest Pain
ECG ON PRESENTATION: ST ELEVATION IN V2-V4
ECG 48 HRS LATER: LARGE GLOBAL TWI, LONG QT EMERGENT CATHETERIZATION:
NORMAL CORONARY ARTERIES
APICAL BALLOONING

69. • Following an acute CNS event:
• Subarachnoid hemorrhage
• Large ICH
• Status epilepticus
• Emotional stress:
• Takotsubo cardiomyopathy
• Any type of adrenergic stress:
• Hypertensive emergency
• Pheochromocytoma attack
• Pulmonary edema
• Severe asthma attack
• Severe trauma
“CEREBRAL T WAVES”
The ECGs All Look
Alike!
Large Near-Global T-Wave Inversion And Marked QT
Prolongation: A Stereotypical Delayed ECG Response To Stress
Cardiomyopathy

70. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED
DRAMATICALLY PROLONGED QT
Day 2: Stress-Induced Cardiomyopathy

71. GLOBAL T WITH PROLONGED QT
NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED
DRAMATICALLY PROLONGED QT
Day 2: Subarachnoid Hemorrhage

72. GLOBAL T WITH PROLONGED QT
NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED
DRAMATICALLY PROLONGED QT
Day 2: Subarachnoid Hemorrhage

73. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED
PROLONGED QT
Day 2: Massive ICH

74. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED
DRAMATICALLY PROLONGED QT
After An Episode Of Status Epilepticus

75. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES;
aVR and V1 SPARED; PROLONGED QT
Day 2: Acute Pulmonary Edema

76. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR SPARED
DRAMATICALLY PROLONGED QT
Following An Acute COPD Exacerbation

77. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR SPARED
DRAMATICALLY PROLONGED QT
Following An Episode Of Hypertensive Crisis

78. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED
DRAMATICALLY PROLONGED QT
ICU Patient With Respiratory Failure & Shock

79. NEAR-GLOBAL T-WAVE INVERSION; GIANT NEGATIVE T WAVES; aVR and V1 SPARED
PROLONGED QT
Following An Acute Episode Of Cocaine Toxicity

80. What Is The Significance Of Recognizing
The “T-QT Pattern”?
• If the clinical history and the ECG are typical for stress response, the large
negative T waves do not necessarily indicate ischemia
• Unnecessary cardiac catheterization can be avoided
• Antithrombotic and anti-ischemic treatment may be avoided
• In acute heart failure if stress cardiomyopathy is a reasonable
consideration, the typical “T-QT pattern” can further support this
possibility

81. If You Have Interesting Cases Of Stress-Induced Cardiomyopathy We Invite You
To Send A Set Of Digital PDF Images And A Brief Descriptive Clinical History To:
michael.gibbs@atriumhealth.org
Your De-Identified Case(s) Will Be Posted On Our Education Website And You
And Your Institution Will Be Recognized!