Can echocardiography or cardiac magnetic resonance imaging differentiate takotsubo syndrome in the acute phase from anterior wall ST-segment elevation myocardial infarction?

Abstract Takotsubo syndrome (TTS) is a syndrome of symptoms of acute heart failure that mimics myocardial infarction (MI). In diagnostic imaging the role of echocardiography is crucial. Nevertheless, echocardiography in differentiating TTS from anterior wall ST-segment elevation myocardial infarction (STEMI) may be insufficient. The purpose of the study was to determine the differences between parameters in echocardiography (echo) and cardiac magnetic resonance (CMR) in study groups and to prove the thesis that CMR is useful to put a proper diagnosis. Nineteen patients (15 females, age 69 ± 10 years) with initial diagnosis of TTS and 10 patients (2 females, age 64 ± 10 years) with initial diagnosis of anterior wall STEMI in the years 2020-2024 were included in the study. In the first days of acute phase of the disease echocardiogram and CMR were done. A comprehensive transthoracic echo was performed using Vivid E95 GE or Vivid S60 GE. Classic echocardiographic parameters and longitudinal strain were obtained. All participants underwent CMR examination on a 1,5-T scanner (Magnetom Aera or Magnetom Sola) or 3-T scanner (Magnetom Vida). The protocols of examination included long-axis and short-axis cine series for anatomy and functional assessment, cardiac parametric mapping sequences for longitudinal (T1) and transverse (T2) relaxation time measurements, myocardial oedema at STIR images, extracellular volume fraction (ECV), late gadolinium enhancement (LGE) and longitudinal strain. Statistical analyses were conducted using Statistica 13 software. There were statistically significant differences in left ventricle ejection fraction (LVEF) in both examinations between groups (51% vs. 42% TTS vs. STEMI in echo and 47% vs. 41% TTS vs. STEMI in CMR). In CMR end-diastolic and end-systolic volumes as well as cardiac output were significantly higher in STEMI. There were no differences in global peak longitudinal strain (GLS) as well as longitudinal strains for 17 segments between both study groups. In 67% of TTS patients and 22% of STEMI patients myocardial oedema in medial segments in CMR were stated and in 89% of TTS patients and 44% of STEMI patient myocardial oedema in apical segments were detected – differences were statistically significant. T2 relaxation time for apical segments was significantly longer in TTS group. In 26% of patients in acute phase of TTS LGE was stated (p=0,0002). In analyses of patients’ characteristic there were no differences in troponin or BNP levels during the admission. In summary, in differential diagnosis between TTS and STEMI, revealing oedema in the apical and middle segments of myocardium in CMR (STIR, T2 mapping) is crucial. LVEF is statistically higher in TTS patients in ECHO and CMR than in STEMI patients. Assessment of GLS does not differentiate these diseases neither in echo nor in CMR. The presence of LGE does not exclude the diagnosis of TTS, although it is characteristic of MI.