Tombstone ST elevation in Takotsubo cardiomyopathy

A 70‐year‐old woman with alcoholism was admitted due to hypokalemic periodic paralysis. The patient's vital signs on presentation were: heart rate, 118 b.p.m.; blood pressure, 98/56 mmHg, and serum potassium level, 1.8 mmol/L. An electrocardiogram (ECG) on presentation showed an upslope‐type ST segment depression in the pericardial leads and prolonged corrected QT interval (Fig. 1A). One day after admission, she suddenly experienced chest tightness after correction of hypokalemia, and her potassium level was 3.5 mmol/L. The ECG showed massive ST segment elevation in the limb and pericardial leads, which is called “tombstone” ST elevation without reciprocal change (Fig. 1B).1, 2 Emergency coronary angiography showed normal coronary arteries, and left ventriculography (Video S1) showed apical ballooning during systole, consistent with Takotsubo cardiomyopathy.1 Treatment with a beta‐blocker (bisoprolol) was initiated. Four days after admission, an inverted T wave appeared on ECG in pericardial leads (Fig. 1C), and echocardiography showed improvement in the hypokinesis in the apical segment.

Figure 1.

Electrocardiograms of a 70‐year‐old woman with Takotsubo cardiomyopathy. (A) The electrocardiogram on admission demonstrates upslope type ST segment depression and prolonged corrected QT interval. (B) The electrocardiogram at day 2 demonstrates tombstone ST elevation in the limb and pericardial leads. (C) The electrocardiogram at day 4 demonstrates inverted T in pericardial leads.

Disclosure

Approval of the research protocol: N/A.

Informed consent: Written informed consent was obtained from the patient.

Registry and the registration no. of the study/trial: N/A.

Animal studies: N/A.

Conflict of interest: None.

Supporting information

Video S1. Left ventriculography in a 70‐year‐old woman with Takotsubo cardiomyopathy shows apical ballooning during systole and hyperdynamic basal segment.