The dramatic ECG changes of hypertrophic obstructive cardiomyopathy mimicking Takotsubo cardiomyopathy: a case report

Link of Video Abstract: https://youtu.be/3rkgy4KqfOA Background: ST-elevation mimicking ST-segment elevation myocardial infarction (STEMI), myocarditis, or takotsubo cardiomyopathy may occur in patients with hypertrophic cardiomyopathy. Echocardiography may also show a rounded apex with ballooning/aneurysm, thus mimicking takotsubo. Therefore, this case study aims to evaluate the dramatic ECG changes of hypertrophic obstructive cardiomyopathy mimicking Takotsubo cardiomyopathy. Case Presentation: A 78-year-old female presented to the emergency department with shortness of breath, palpitations, and back pain radiating to both arms. She was hypotensive, with ST elevation, R wave, and T wave inversion in the anteroinferior leads, a normal T wave in aVR, and a wide P wave on the admission ECG. Her NTpro-BNP and hs-TnT levels were elevated. Coronary angiography revealed a non-significant lesion. The echocardiogram showed a dilated LV with rounded apical LV, suggesting Takotsubo syndrome. ECGs from days 3 to 5 before discharge showed normalization of the ST segment. A CMR performed 2 weeks later demonstrated asymmetrical hypertrophic cardiomyopathy with sigmoid hypertrophy of the septal ventricular wall and hypertrophy of the anterolateral and posteromedial papillary muscles, causing narrowing of the left ventricular outflow tract (LVOT) during systole, with turbulence at the LVOT. Conclusion: HCM can cause dramatic changes in ECG features, especially during the acute dynamic phase of LVOT obstruction. Additionally, the upright T wave in aVR, a valuable clinical tool and simple visual criterion in ECG, may provide useful information regarding the unfavorable prognosis of patients with HCM.