Role of cardiac magnetic resonance in the differential diagnosis of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) is a transient form of acute heart failure triggered by stressful events and associated with a typical left ventricular ballooning. Cardiac magnetic resonance imaging may be helpful in the diagnosis of this syndrome, particularly when differential diagnosis with acute coronary syndrome (ACS) is not easy. We report 2 cases in which the distinction between TTC and ACS was required because of overlapping clinical presentation and presence of normal coronary angiography. Cardiac magnetic resonance imaging was therefore performed with the aim to distinguish the 2 clinical entities. The presence of localized edema in the midbasal segments of the lateral wall and the presence of subendocardial late enhancement in the basal segment of the inferolateral wall in case 1 were likely to be indicative of myocardial infarction in normal epicardial coronary arteries and microcirculation disease. The typical localization of edema to midapical segments of the left ventricle in the absence of late enhancement in case 2 was indicative of TTC. The evaluation with cardiac magnetic resonance imaging of myocardial edema and myocardial scar/fibrosis allowed the prompt distinction between acute ischemic heart disease and TTC. Cardiac magnetic resonance imaging at admission may provide relevant functional and tissue information that might be useful in the diagnosis of TTC and in differential diagnosis with ACS.