Acute coronary syndrome (ACS) vs Takotsubo cardiomyopathy/myocarditis

Introduction: The objective of this paper is to highli-ght the importance to distinguish the three entities: Acute Coronary Syndrome (ACS)/ Takotusubo Car-diomyopathy/Myocarditis based on signs, symptoms, paraclinical exploration and the particularity of the optimal therapeutic course. The term ACS is used for any suddenly triggered condition characterized by a decrease in blood flow to the myocardium. Takotsubo cardiomyopathy also known as stress-induced cardi-omyopathy or apical ballooning of the left ventricle is a reversible acquired pathology, characterized by acu-te systolic dysfunction. Myocarditis is an inflammato-ry disease of the myocardium, this condition remains a challenge in terms of diagnosis as it is manifested through various clinical pictures. Clinical presentation of the patients together with paraclinical investigations help distinguish between these three entitis.

Methods: In this paper we discuss an atypical case of cardiovascular disease in a young patient with risk fac-tors, who was admitted in the emergency department for epigastric sharp pain, lasting a few minutes, witho-ut radiation, accompanied by nausea and physical as-thenia. Onset of symptoms started 2-3 hours prior to being admitted in the emergency department withing Craiova 1st County Emergency Hospital. Initially, based on clinical presentation, acute ECG changes and eleva-ted biomarkers, it was diagnosed as ACS and treated accordingly adapted to ESC guidelines. On further re-evaluation of the patient with advanced imaging tech-niques such as MRI the diagnosis of myocarditis was stabilished and appropriate treatment was initiated.

Results: Myocarditis is highly polymorphic, depending on the etiological type, the extent and location of the le-sions, the age of the patient and possible associated car-diac pathology. In our case, the patient had a favorable evolution despite significant ECG changes, impressive dynamics of myocardial necrosis markers and clinical presentation. Coronarography revealed a stenosis of 20% in segment II of LAD, which is why we continu-ed further investigations. Among other test numerous laboratory tests have been performed on viral / bacte-rial etiology of myocarditis, but the only change was in coagulation factor VIII. Cardiac MRI was performed, which revealed: Contrast enhancement at the level of anterior interventricular septum, anterior wall and all other segments, diffuse, imprecisely delimited, compri-sing the entire thickness of the myocardial wall.

Conclusions: MRI changes suggestive of acute myo-carditis. Myocarditis is the consequence of a wide range of myocardial lesions it represents a challenging diagno-sis, mainly because there is no pathognomonic clinical presentation, and the disease may masquerade as a va-riety of non-inflammatory myocardial diseases which could cause confusion in diagnosis and that could be fatal for the patient. Cardiac MRI used as a diagnostic test in suspected myocarditis, increasing the sensitivity and specificity of this pathology. Myocarditis remains a challenge in terms of diagnosis, because it is mani-fested by various clinical pictures. In order to establish the diagnosis of myocarditis, high degree of suspicion as well as optimal investigations are required for promt detection and appropriate treatment.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)