Image Diagnosis: Takotsubo Cardiomyopathy Mimicking an Acute ST Elevation Myocardial Infarction in the Setting of Anti-Depressant Therapy Withdrawal

A 77-year-old woman with a history of bipolar disorder, hypertension, hyperlipidemia, and previous tobacco use presented to the Emergency Department (ED) with acute shortness of breath and diaphoresis. The patient was initially anxious and tearful upon presentation to the ED. While she denied acute emotional or social stressors, she did note abruptly stopping her venlafaxine (brand name Effexor) approximately 3 weeks before. Results of an initial electrocardiogram (ECG) showed an ectopic atrial rhythm with marked diffuse ST-segment elevation most prominent in the anterolateral leads (Figure 1). Results of bedside echocardiography demonstrated a large territory of hypokinesis involving all apical segments with hypercontractile basal segments (Figure 2). Emergent invasive coronary angiography was performed, which demonstrated no obstructive coronary artery disease. Initial troponin I level was 1.26 ng/mL (normal < 0.04 ng/mL). Results of a subsequent ECG obtained at 4-week follow-up illustrated resolution of previously seen ST elevations, now with anterolateral T-wave inversions (Figure 3). Results of repeat echocardiography at 4-week follow-up demonstrated normalization of left ventricular systolic function and no segmental wall-motion abnormalities.