Comparison on the clinical characteristics of patients with Takotsubo syndrome from China and from Europe/North America / 中华心血管病杂志

Objective: To summarize the clinical characteristics of patients with Takotsubo syndrome (TTS) from China and compare these features with patients from Europe/North America. Methods: We reviewed case reports published between 1990 and 2020 with the key words of "Takotsubo syndrome" "stress cardiomyopathy" "apical balloon syndrome" and "broken heart syndrome", in Wanfang, CNKI, Pubmed and Web of Science databases, and 1 294 articles were identified, including 128 articles reporting 163 cases in China and 1 166 articles reporting 1 256 cases in Europe/North America. The characteristics of demographics, triggers, symptoms, electrocardiogram, echocardiography, left ventriculogram,coronary angiography, treatment and prognosis were analyzed and compared between Chinese and European/North American cases. Results: A total of 1 294 articles (1 419 cases: 163 from China, 1 256 from Europe/North America) were included in the final analysis. The characteristics of Chinese cases included: (1) demographic:the age was (59.6±16.9) years, which was similar with that of European/North American ((59.7±17.4) years, P=0.90), and female accounting for 78.5% (128/163), which was lower than that of European/North American (85.4% (1 073/1 256), P=0.02). (2) Triggers:mental triggers accounted for 48.5% (79/163), physical triggers accounted for 43.6% (71/163), and no triggers accounted for 7.9% (13/163), respectively. Compared with Europe/North America, the ratio of patients with mental triggers was higher in China, while the ratio of patients with physical triggers and no triggers was lower (P<0.05). (3) Symptoms: chest pain (52.8% (86/163)), chest tightness (35.0% (57/163)), shortness of breath (33.1% (54/163)), dizziness (16.0% (26/163)), sweating (15.3% (25/163)), palpitations (12.3% (20/163)), syncope (9.2% (15/163)) abdominal pain/diarrhea (8.6% (14/163)), hypotension (7.4% (12/163)), and fatigue (1.2% (2/163)) were illustrated in sequence. Compared with patients in Europe/North America, the ratio of patients with chest tightness, dizziness, sweating, palpitations, abdominal pain/diarrhea was higher in Chinese patients, while the ratio of patients with hypotension was lower in Chinese patients (P<0.05). (4) Electrocardiogram: main manifestations were myocardial ischemia symptoms, such as ST-segment elevation (63.8% (104/163)), T wave inversion (46.0% (75/163)), ST-segment depression (8.6% (14/163)). Compared with European/North American, the ratio of patients with ST-segment elevation, T wave inversion, and atrioventricular block was higher in Chinese patients (P<0.05). (5) Echocardiography and imaging:apical dyskinesia (59.5% (97/163)) and apical/left ventricular bulbar dilation (36.2%(59/163)) dominated the echocardiography findings. Compared with European/North American, the ratio of patients with apical dyskinesia, apical/left ventricular bulbar dilation, and mitral regurgitation was higher in Chinese patients, while the ratio of patients with dyskinesia in other parts and left ventricular ejection fraction<50% was lower in Chinese patients (P<0.05). Left ventricular angiography showed 36.2% (59/163) of apical dyskinesia in Chinese patients, which was higher than that reported in European/North American patients, and 38.7% (63/163) of apical/left ventricular bulbar dilation was reported in Chinese patients, which was similar to that reported in European/North American patients. Coronary angiography showed percent of no stenosis or stenosis less than 50% was 87.1% (142/163), which was similar to that reported in European/North American patients (P>0.05). The typical type of TTS accounted for 96.3% (157/163), which was significantly higher than that reported in European/ American patients, while the ratio of basal type and midventricular type was lower (P<0.01). (6) Treatment and prognosis:the applied drugs in China were listed in order as following, β-blockers (41.1% (67/163)), antiplatelet agents (37.4%(61/163)), ACEI/ARB (36.2%(59/163)), anticoagulants (27.0%(44/163)), diuretics (19.6% (32/163)), etc. Compared with Europe/North America, the ratio of antiplatelet agents, anticoagulants, statins, diuretics, and nitrates use was higher in China (P<0.05), while the use of oxygen therapy and IABP was similar (P>0.05). The hospital mortality in China was 5.5% (9/163), during 1-year follow-up the recurrence rate was 3.7% (6/163) and the mortality was 0. The prognosis was similar with that in Europe/North America. Conclusions: Compared with TTS cases in Europe/North America, TTS cases in China also occur usually in middle-aged and elderly women, most of whom have mental/physical triggers and typical imaging manifestations, followed by a low hospital mortality rate and recurrence rate.

Mourning and Takotsubo cardiomyopathy: neuroendocrine implications and nutritional management

SUMMARY This article aims to make reference to some recent mourning aspects considered risk factors for cardiovascular disease, specifically the Takotsubo cardiomyopathy. The objective was to describe the stress from the death of a loved one combining it to the possibility of occurrence of Takotsubo cardiomyopathy through the perception of a traumatic event by the cortex, which triggers the subcortical brain circuit affecting the endocrine response. Given the growing acknowledgement of this cardiomyopathy, it is possible to contextualize the nutritional behaviours and decisions surrounding it, whose benefits must exceed the condition of temporary cardiac dysfunction and extend to food choices that have some influence in the limbic system. It is a descriptive analysis that aims to problematize the theme into reflections based on this experience, considering the foundation with the science of nutrition.

RESUMO INTRODUÇÃO: Este artigo busca fazer referência a alguns aspectos do luto recente considerados fatores de risco para a doença cardiovascular, específicamente a cardiomiopatia de Takotsubo. Objetivou-se descrever o estresse proveniente da morte do ente querido aliando-o à possibilidade de ocorrência da cardiomiopatia de Takotsubo, mediante a percepção de um evento traumático pelo córtex que aciona o circuito cerebral subcortical tendo repercussões na resposta endócrina. Dado o crescente reconhecimento dessa cardiomiopatia, torna-se viável contextualizar as condutas nutricionais e as decisões que as norteiam, cujos benefícios devem ultrapassar a condição de disfunção cardíaca temporária e se estender às escolhas alimentares que exercem alguma influência no sistema límbico. Trata-se de uma análise descritiva que objetiva problematizar a temática em reflexões pautadas nessa vivência, considerando o alicerce com a ciência da nutrição.

Stress induced cardiomyopathy due to a Mexican earthquake / Cardiomiopatía por estrés inducida por el terremoto en México

Abstract Takotsubo Cardiomyopathy mainly occurs in postmenopausal women, with or with- out cardiovascular disease, and is commonly associated with emotional or physical stress. After nearly 27 years of extensive efforts towards a better understanding of this disorder, current knowledge remains limited. Many people suffer post-traumatic stress, and this situation can be associated to stress cardiomyopathy. The case is presented of a female who suffers stress asso- ciated with the earthquake of 19 September 2017 in Mexico City, and arrived in the Emergency Department in cardiogenic shock.

Resumen La miocardiopatía de Takotsubo ocurre principalmente en mujeres posmenopáusicas con o sin enfermedad cardiovascular, y se asocia comúnmente con estrés emocional o físico. Después de casi 27 an˜os de esfuerzos extensos para una mejor comprensión de este trastorno, el conocimiento actual sigue siendo limitado. Muchas personas sufren estrés postraumático y esta situación puede estar asociada a la cardiomiopatía por estrés. Presentamos el caso clínico de una mujer que sufrió estrés relacionado con el pasado terremoto del 19 de septiembre en la Ciudad de México y llegó al servicio de urgencias en choque cardiogénico.

Uso de oxigenação por membrana extracorpórea para tratamento de miocardiopatia aguda após transplante hepático: relato de caso / Use of extracorporeal membrane oxygenation for treating acute cardiomyopathy after liver transplantation: a case report

RESUMO Reportamos o caso de paciente do sexo feminino, 58 anos, sem doença cardíaca conhecida, submetida a transplante hepático sem intercorrências. No segundo dia do pós-operatório desenvolveu choque cardiogênico secundário à miocardiopatia induzida pelo estresse (síndrome de Takotsubo-like). A paciente foi manejada com sucesso com oxigenação por membrana extracorpórea venoarterial periférica, por 6 dias, com recuperação completa da função cardíaca, bem como do enxerto hepático. Síndrome coronariana e miocardite aguda foram excluídas como causas do choque. O uso de oxigenação por membrana extracorpórea neste cenário é possível e seguro, considerando protocolos e tratamento especializado neste tipo de suporte.

ABSTRACT We report the case of a female patient, 58 years of age, without known heart disease, who underwent liver transplantation without complications. On the second postoperative day, the patient developed cardiogenic shock secondary to stress-induced cardiomyopathy (Takotsubo-like syndrome). The patient was successfully managed with veno-arterial peripheral extracorporeal membrane oxygenation for 6 days, with complete recovery of cardiac function and of the hepatic graft. Coronary syndrome and acute myocarditis were excluded as the causes of the shock. The use of extracorporeal membrane oxygenation in this scenario is possible and safe, considering its specialized protocols and treatment.

Síndrome de tako-tsubo, caracterización clínica y evolución a un año plazo / Tako-tsubo syndrome: analysis of 37 cases

Background: Tako-tsubo Syndrome (TTS) is characterized by transient regional systolic dysfunction of the left ventricle (LV), mimicking myocardial infarction. It accounts for 0.9-1.2% of all acute coronary syndromes (ACS). Aim: To describe the incidence and characteristics of TTS within our population. Material and Methods: All patients diagnosed with ACS and TTS were selected from a clinical registry of all the coronary angiographies done in our hospital. Clinical features during initial presentation, hospital evolution and one year follow-up were analyzed. Results: The first case diagnosed in our hospital occurred in 2001. Since then, 4,433 coronary angiographies were done to patients with ACS until 2014 and 37 corresponded to TTS (0.83% incidence). The mean age of patients was 64 years, 73% were female, and 62% had hypertension. All patients had an identifiable trigger factor, abnormal EKG and elevated troponin. The coronary angiography did not show lesions in 97%. However, all had the characteristic extensive segmental-motility alteration with a mean ejection fraction of 44%. All patients were treated initially as an ACS. Seven patients had complications, namely acute cardiac failure in six and stroke in one. No patient died. At one year of follow-up, 100% showed normal segmental motility and ejection fraction, no patient had a new episode of TTS and all were alive. Conclusions: TTS is rare and the incidence found in this study is slightly lower than that reported elsewhere. TTS mimics ACS and it should be suspected by its clinical, electrocardiographic and enzymatic particularities. Coronary angiography helps to rule out other diagnosis. All patients normalize motility and ventricular function, which is the definitive differential feature respect to ACS.

Miocardiopatía de Tako-Tsubo: una manifestación inusual de feocromocitoma / Takotsubo cardiomyopathy: rare manifestation of pheochromocytoma

Takotsubo cardiomyopathy (MTT) is an acute ventricular dysfunction and reversible in absence of coronary disease. It is a rare presentation of pheochromocytoma and paraganglioma (FPGL). It was described for the first time in 1990 by Sato et al, the physiopathology is not clear yet. It is associated with high levels of catecholamines, vasospasm in the micro vascularization, rupture of atheromatous plaque and myiocarditis. The clinical presentation is similar to an acute myocardial infarction because of that the FPGL must be considered in patients without obstructive coronary lesions. We present a case of a 50 years old women with history of Arterial Hypertension, active smoking and Neurofibromatosis, who is admitted to emergency room with an acute myocardial pain.

Miocardiopatía Takotsubo postparto: parto distócico como posible factor desencadenante / Takotsubo cardiomyopathy: dystocic labor as a possible triggering factor

La miocardiopatía Takotsubo, o miocardiopatía por estrés, se define como una disfunción del segmento apical del ventrículo izquierdo, aguda, transitoria y reversible. Normalmente se relaciona con algún tipo de agente estresante, ya sea físico o emocional, pudiendo confundirse este cuadro con un síndrome coronario agudo. Se considera una patología rara, pero que es importante incluir en el diagnóstico diferencial de los trastornos cardiacos, sospechándolo previamente por la sintomatología. Está caracterizado por alteraciones en el electrocardiograma, como elevación del segmento ST en derivaciones precordiales e inversión de la onda T, elevación de las enzimas de necrosis miocárdica o patrones alterados en la ecocardiografía, como la disfunción ventricular apical con hiperquinesia de zonas basales. En cuanto a la fisiopatología, parece que la estimulación simpática juega un papel importante, en el que la disfunción ventricular se desencadena por algún tipo de estrés físico o emocional. Éste provoca una descarga de catecolaminas con un efecto cardiotóxico debido, en su mayor parte, al efecto del adenosín monofosfato cíclico. El tratamiento consiste en las medidas soporte de una miocardiopatía, evitando los fármacos teratogénicos o perjudiciales durante el periodo de lactancia. La evolución es favorable en la mayoría de los casos y el cuadro remite por completo, por lo que el pronóstico en líneas generales se considera bueno. En este trabajo se expone el caso de un parto instrumentado, en el que se manifiesta un cuadro compatible con una miocardiopatía Takotsubo, posiblemente relacionado con un procedimiento invasivo como factor desencadenante.

Takotsubo cardiomyopathy or stress cardiomyopathy is defined as an acute, transient, and reversible dysfunction of the apical segment of the left ventricle. It is usually associated with some sort of stressor, whether physical or emotional, and could be confused with an acute coronary syndrome. It is considered a rare disease, so it is important to include it in the differential diagnosis, previously suspecting the symptoms. It is characterized by alterations in the electrocardiogram such as ST segment elevation and inversion of the T wave in precordial leads, elevation of myocardial necrosis enzymes, or altered patterns on echocardiography such as apical ventricular dysfunction with hyperkinesia of basal areas. Regarding the pathophysiology, it seems that sympathetic stimulation plays an important role, in which ventricular dysfunction is triggered by some kind of physical or emotional stress. This causes a release of catecholamines with cardiotoxic effects due, mostly, to the effect of cyclic AMP. Treatment involves cardiomyopathy supportive care, avoiding teratogenic or harmful drugs during lactation. The evolution is favorable in most cases and the clinical picture abates completely, so the prognosis is generally considered good. In this paper, we expose a case of an instrumental labor in which a clinical picture compatible with Takotsubo cardiomyopathy is presented, triggered by an invasive procedure.

Cardiomiopatia de Takotsubo após pneumonia: relato de caso / Takotsubo cardiomyopathy after pneumonia: case report

Também chamada de Síndrome do Coração Partido, a Síndrome de Takotsubo é uma doença cardiovascular com quadro clínico semelhante ao infarto agudo do miocárdio, porém, com coronárias normais na cineangiocoronariografia. Normalmente está associado a quadros de estresse emocional ou físico sendo necessário o conhecimento da patologia para diagnóstico e boa condução do caso. O objetivo deste estudo foi relatar um caso clínico de uma paciente com cardiomiopatia de Takotsubo após pneumonia e internação hospitalar. A importância do tema é ressaltada pela raridade do tema e pelo seu subdiagnóstico. Mulher,77 anos com história de disfagia de transferência evoluindo após 10 dias com tosse produtiva de coloração amarelada. Diagnosticada e internada com pneumonia broncoaspirativa e iniciada antibioticoterapia. No sétimo dia de internação evoluiu com precordialgia associada a dispneia. História mórbida de acidente vascular cerebral (AVC) isquêmico há 4 anos com sequela de hemiplegia esquerda e crises convulsivas. O eletrocardiograma (ECG) demonstrou supradesnivelamento do segmento ST emparede ântero-septal. À cinecoronariografia ausência de lesões obstrutivas significativas e à ventriculografia e ecocardiograma discinesia de ventrículo esquerdo com abalonamento ântero-infero-apical. No caso descrito os fatores desencadeantes ficaram claros sendo o estresse físico pela pneumonia e emocional pela internação hospitalar. O quadro clínico apresentado pela paciente associado a cinecoronariografia, ecocardiografia e eletrocardiografia e o padrão de reversibilidade da disfunção cardíaca nos remetem ao diagnóstico de Cardiomiopatia de Takotsubo.

Also called the Broken Heart Syndrome, Takotsubo syndrome is a cardiovascular disease similar to acute myocardial infarction clinical, however, with normal coronary arteries on coronary angiography. Is usually associated with events of emotional or physical stress. The knowledge of pathology for diagnosis and good management of the case is necessary. The aim of this study was to report a clinical case of a patient with Takotsubo cardiomyopathy after pneumonia and hospitalization. The importance of this issue is underscored by the rarity of the subject and its underdiagnosis. Female, 77 years with a history of dysphagia transfer evolving after 10 days with cough productive of yellowish. She was diagnosed with aspiration pneumonia and hospitalized with antibiotic therapy initiated. On the seventh day of hospitalization developed chest pain associated with dyspnea. Morbid history of ischemic stroke 4 years ago sequel with left hemiplegia and seizures. The ECG showed ST segment elevation in the anteroseptal wall. In the absence of significant obstructive coronary angiography and ventriculography lesions and echocardiographic left ventricular dyskinesia with anterior infero-apical bulging. In the case described, the triggering factors were the physical and emotional stress by the pneumonia and hospitalization. The clinical presentation by the patient associated with coronary angiography, echocardiography and electrocardiography and standard reversibility of cardiac dysfunction refer us to diagnosis of the Takotsubo Cardiomyopathy.

Cardiomiopatía inducida por estrés (Takotsubo) en una paciente con anorexia nerviosa / Stress (Takotsubo) cardiomyopathy in a patient with anorexia nervosa

Presentamos el caso de una mujer con diagnóstico de anorexia nerviosa que desarrolló cardiomiopatía de takotsubo precipitada por estrés emocional y alteraciones del medio interno. Evolucionó favorablemente con manejo conservador. Los casos de cardiomiopatía inducida por estrés, descriptos en pacientes con trastornos de la conducta alimentaria, suelen alcanzar mayor gravedad y se asocian con la prolongación del intervalo QT por desequilibrios electrolíticos, arritmias ventriculares e hipoglucemia. Se realiza una revisión del compromiso cardiovascular en pacientes con anorexia nerviosa.

We report the case of a woman with anorexia nervosa who developed takotsubo cardiomyopathy triggered by emotional stress and electrolyte disturbances. The patient improved with conservative management. Descriptions of stress-cardiomiopathy in association with eating disorders are often of higher severity and related to QT prolongation because of electrolyte abnormalities, ventricular arrhythmias and hypoglycemia. A review of cardiovascular compromise in patients with anorexia nervosa is performed.

Postoperative Takotsubo cardiomyopathy.

Takotsubo cardiomyopathy also known as transient apical ballooning syndrome or stress induced reversible cardiomyopathy is an increasingly reported syndrome generally characterized by transient systolic dysfunction of the apical and/or mid segment of the left ventricle. It is frequently precipitated by severe stress and clinically mimics an acute ST‑elevation myocardial infarction, with angiographically normal coronary arteries. A high index of suspicion is needed to diagnose this syndrome. We describe a patient who developed Takotsubo cardiomyopathy in the post‑operative period following vaginal hysterectomy.

Uso de betabloqueador no choque cardiogênico da cardiomiopatia de Takotsubo / Use of beta-blockers in cardiogenic shock due to Takotsubo cardiomyopathy

A cardiomiopatia de Takotsubo se caracteriza por alterações reversíveis na função sistólica e segmentar do ventrículo esquerdo associada à coronariografia normal. O choque associado a essa cardiomiopatia é causado por disfunção sistólica e/ou obstrução dinâmica do trato de saída do ventrículo esquerdo. A identificação da etiologia do choque tem implicações terapêuticas. Relata-se o caso de paciente feminina, 76 anos, com cardiomiopatia de Takotsubo cuja apresentação mimetizou infarto agudo do miocárdio complicado com choque cardiogênico. O choque foi revertido após administração endovenosa de propranolol.

Takotsubo cardiomyopathy is characterized by reversible changes in the systolic and segmental left ventricular function associated with normal coronariography. The shock associated with this cardiomyopathy is caused by left ventricular systolic dysfunction and/or dynamic left ventricular outflow tract obstruction. Identification of the etiology of the shock has implications for treatment. This case study reports on a 76-year-old women diagnosed with Takotsubo cardiomyopathy whose presentation mimicked an acute myocardial infarction complicated by cardiogenic shock. The shock was reversed after intravenous administration of propanolol.

Cardiomiopatia de Takotsubo em octogenária / Takotsubo cardiomyopathy in octogenarian

Mulher, 88 anos, é admitida na emergência com dor anginosa típica, retroesternal, forte intensidade, em aperto, com duração maior que 30 minutos, associada à dispneia, náuseas, lipotímia, sudorese moderada e apresentando supradesnivelamento de segmento ST ao eletrocardiograma após intensa discussão familiar. Paciente é conduzida inicialmente como infarto agudo do miocárdio com supradesnivelamento de segmento ST. Na cineangiocoronariografia, evidenciou-se ausência de lesões em artérias coronárias e balonamento de parede anterior semelhante a um haltere, recebendo diagnóstico de cardiomiopatia de Takotsubo.

Female, 88 years old, admitted to the Emergency Department in distress after a heated family discussion, with high intensity retrosternal typical anginal pain lasting more than 30 minutes, associated with moderate sweating, dyspnea, nausea and fainting, with ST-segment elevation in the electrocardiogram. Patient initially treated as an acute myocardial infarction with ST-segment elevation. Cinecoronary angiography showed an absence of coronary artery lesion with the anterior wall ballooning like a dumbbell, diagnosed as Takotsubo cardiomyopathy.

Síndrome del corazón roto: cardiomiopatía de Tako-Tsubo: [revisión] / Broken heart syndrome: Tako-Tsubo cardiomyopathy: [review]

La cardiomiopatía de Tako-Tsubo se define como una cardiopatía súbita, aguda, caracterizada por alteraciones en la contractilidad de los segmentos apicales del ventrículo izquierdo, lo que lleva de manera rápida e importante a un defecto de bomba a nivel cardíaco, causando sintomatología de diversa gravedad que puede implicar incluso el desarrollo de choque cardiogénico y la muerte. Se caracteriza, entre otros, por una ausencia absoluta de lesiones detectables a la angiografía coronaria. A pesar que no existe a la fecha un consenso al respecto, actualmente se considera que las teorías que mejor explican el síndrome son las alteraciones de la microcirculación coronaria y la toxicidad miocárdica por catecolaminas. Su cuadro clínico se basa principalmente en dolor precordial, asociado a disnea; las enzimas de mionecrosis (principalmente las troponinas) pueden estar aumentadas levemente, aunque es característica la presencia de una coronariografía completamente normal.

Tako-Tsubo cardiomyopathy is defined as a sudden, acute cardiomyopathy, characterized by reversible alterations in left ventricle’s apical segments contractility, resulting in an important decrease in the heart’s ‘pumping’ function. This causes various degrees of symptomatology in the patient, including, in some cases, cardiogenic shock and death. This condition is characterized, specially, by an absolute lack of detectable lesions on coronariography. Although to date there is no consensus on this issue, now considered the theories that best explain the syndrome include abnormalities of the coronary microcirculation and myocardial catecholamine toxicity. The clinical presentation of most patients will include chest pain and dyspnea, with troponins been elevated in some cases, although there will always be the characteristic of a completely normal angiographic study.

Síndrome do coração partido (Síndrome de Takotsubo) induzida por ecocardiograma de estresse com dobutamina / Síndrome del corazón roto (síndrome de Tako-Tsubo) inducido por ecocardiograma de esfuerzo con dobutamina / Dobutamine stress echocardiography-induced broken heart syndrome (Takotsubo Syndrome)

Relatamos um caso de síndrome de Takotsubo induzida por ecocardiograma de estresse com dobutamina em uma paciente de 76 anos, hipertensa com queixas clínicas de dor precordial, em consulta cardiológica eletiva. Para exclusão de dor torácica de etiologia coronariana foi solicitado ecocardiograma de estresse com dobutamina. O exame foi realizado e, no pico do esforço máximo, o ecocardiograma mostrou acinesia apical com o eletrocardiograma mostrando supradesnivelamento do segmento ST em D1, AVL e V2. A paciente foi internada e submetida a coronariografia, que mostrou coronárias normais e VE com balonamento apical. A paciente evoluiu estável com reversão do quadro 21 dias após o quadro inicial.

We report a case of dobutamine stress echocardiography-induced Takotsubo syndrome in a 76-year-old hypertensive patient with clinical complaints of chest pain in an elective visit to the cardiologist. Dobutamine-stress-echocardiography was requested to rule out chest pain of coronary origin. During the test, at peak exercise, echocardiogram showed apical akinesia and electrocardiogram showed ST-segment elevation in D1, AVL, and V2. The patient was hospitalized and underwent coronary angiography, which showed normal coronary arteries and left ventricular apical ballooning. During follow-up, the patient's condition remained stable, with regression of the manifestations 21 days after the initial presentation.

Relatamos un caso de síndrome de Tako-Tsubo inducido por ecocardiograma de esfuerzo con dobutamina en una paciente de 76 años, hipertensa con quejas clínicas de dolor precordial, en consulta cardiológica electiva. Para exclusión de dolor torácico de etiología coronaria se solicitó ecocardiograma de esfuerzo con dobutamina. El examen fue realizado, y en el pico de esfuerzo máximo, el ecocardiograma mostró acinesia apical con el electrocardiograma mostrando supradesnivel del segmento ST en D1, AVL y V2. La paciente fue internada y sometida a coronariografía, que mostró coronarias normales y VI con abombamiento apical. La paciente evolucionó estable con reversión del cuadro 21 días después del cuadro inicial.