Elias Hanna, MD LSU Cardiology Global T inversion Elias Hanna, MD LSU Cardiology

Patient presents with acute pulmonary edema and mildly increased troponin 0.12

Normal sinus rhythm Global T wave inversion (>10 mm) in most leads with prolonged QTc (~560 msec)

What is Global (Diffuse) T-wave inversion? T wave is inverted in most of the standard leads except aVR, which shows a reciprocal upright T wave. The QT interval is often prolonged, and T-wave inversion is often symmetric and “giant” (> 10 mm, i.e, > 2 big boxes). This is different from Wellens T waves, wherein the T abnormality is limited to the anterior leads (esp V2-V4) and ST segment is slightly upsloping

Causes of Global T-wave inversion 1-Myocardial ischemia 2-Intracranial hemorrhage or any intracranial process 3-Hypertrophic cardiomyopathy 4-High catecholamine states: cocaine use, pheochromocytoma, Takotsubo (stress-induced) cardiomyopathy 5-Other: peri/myocarditis, high-grade AV block, PE Most common

Coronary angiography shows non-obstructive CAD Echocardiogram and Lvgram show apical dyskinesis with preserved basal contractility and EF ~20% Acute non-ischemic HF Low EF with apical dyskinesis Mild troponin increase Deep T inversion No CAD Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy OR: Stress-mediated cardiomyopathy Apical ballooning syndrome Broken heart syndrome

95% of Takotsubo cases are seen in Females>55 yo 95% of Takotsubo cases are seen in Females>55 yo. It is very uncommon in men or <50 yo Usually presents as CP with mild increase in troponin and ST-elevation in the anterior leads, mimicking STEMI ST elevation is followed by deep T inversion with prolonged QT. If diagnosed at this stage, Takotsubo mimicks NSTEMI HF presentation is less common (17%)

Functional MR is seen in 20% of cases, related to tethering of the mitral valve Very good prognosis with a low risk of early death or compplications (VT, stroke, cardiogenic shock) ~1% risk of death LV dysfunction always resolve within 2 months, usually 1-2 weeks Recurrence 11% over 4 yrs