IMAGES THAT TEACH
Myocardial perfusion scintigraphy during chest
pain: An atypical presentation of takotsubo
Maria Marta Maggiotto Sabra, MD,
o Costa, MD,
Jader Cunha de Azevedo, PhD,
Claudio Tinoco Mesquita, PhD,
Hein J. Verberne, PhD
Department of Nuclear Medicine, ProCardiaco Hospital, Rio de Janeiro, Brazil
Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam,
Received Apr 9, 2018; accepted Apr 9, 2018
Although Takotsubo cardiomyopathy (TCM) knowledge is increasing, the exact pathophysi-
ology remains unclear. TCM represents 1%–2% of all troponin positive acute coronary
syndromes, affects predominantly postmenopausal women, and is commonly preceded by
exposure to severe physical or emotional stress. Transient wall motion abnormalities mimicking
ST-elevation myocardial infarction is expected as well as increase of troponin levels and
echocardiography alterations. This case report is about a patient that as far as we know is the
ﬁrst case that shows the use of myocardial perfusion imaging in the acute phase of TCM. In
general, the TCM Mayo Clinic diagnostic criteria have been very helpful in the clinical setting.
In this speciﬁc case, however, the presence of reduced myocardial perfusion in the acute phase
combined with increased troponin levels seemed to be in contradiction with the exclusion of
obstructive coronary artery disease.
Key Words: Takotsubo
Æ cardiomyopathy Æ myocardial perfusion
Although Takotsubo cardiomyopathy (TCM)
knowledge is increasing, the exact pathophysiology
remains unclear. TCM represents 1%–2% of all troponin
positive acute coronary syndromes, affects predomi-
nantly postmenopausal women and is commonly
preceded by exposure to severe physical or emotional
stress. Transient wall motion abnormalities mimicking
ST-elevation myocardial infarction (STEMI) can be
expected as well as increase of troponin levels and
(echocardiographic) wall motion abnormalities.
Although the TCM Mayo Clinic diagnostic criteria have
helped in establishing diagnosis (i.e., including among
others exclusion of coronary artery disease or acute
plaque rupture), TCM remains a challenge to diagnose.
A 48-year-old female patient presented at the
emergency department of a tertiary hospital with typical
angina after severe emotional stress (i.e., the death of a
relative very important to her). Prior to this event, she
had never experienced any complaints of thoracic
discomfort. Pain persisted for approximately 60 minutes.
She had a positive family history for coronary artery
disease and used ﬂuoxetine for a minor depression.
Physical exam was normal. The electrocardiogram
showed no changes and the echocardiogram showed
akinesia of the mid-ventricular segments.
To exclude myocardial ischemia, myocardial per-
fusion scintigraphy was requested according to a chest
Reprint requests: Maria Marta Maggiotto Sabra, MD, Department of
Nuclear Medicine, ProCardiaco Hospital, Rio de Janeiro, Brazil;
J Nucl Cardiol
Copyright Ó 2018 American Society of Nuclear Cardiology.