Bizarre T-wave Inversions in a Patient without Chest Pain

This was sent by a recent ultrasound fellow, asking for my ECG diagnosis. He stated that it is " an acute change from previous " in an elderly smoker with hypertension, syncope, and abdominal pain.There is ST elevation in I, II, III, aVF, V2, V3, V4, V5, and V6.There is bizarre T-wave inversion with very long QT in all these leadsWhat is this?My response:" These are typical of Takotsubo or CNS catastrophe.Obviously it is clinically not a CNS catastrophe, so it must be Takotsubo.You must have done an echo?Apical ballooning? "His answer:" It was Takotsubo! Sadly I did not perform my own echo.  It was a busy shift, fewer US machines are available here, so I could not find one in that moment.  Cards came to see the patient and brought their machine down, and he had clear apical ballooning and the cath lab was activated in the middle of the night (a little begrudgingly).  The angiogram was negative. "CommentNotice that I did not even put ACS on my differential?  These ECGs, in my experience, are not seen  in ACS.  However, there are morphologies of Takotsubo that cannot be distinguished from STEMI.  See below.Here are some examples:1.Takotsubo Stress Cardiomyopathy that mimics LAD occlusionCath was clean. 2.Central Nervous System T-waves. This one is called:"Spiked Helmet Sign"3.TakotsuboTypical Takotsubo, very unlikely to be ACS because of extremely long QTPresented with altered mental status, hypotension, and mild chest...

Source: Dr. Smith's ECG Blog - October 22, 2017 Category: Cardiology Authors: Steve Smith Source Type: blogs