A postmenopausal woman experiences a stress trigger and shows ballooning of the left ventricle on echocardiography. What is the most likely diagnosis?

• A. Aortic dissection
• B. Acute myocardial infarction
• C. Takotsubo cardiomyopathy
• D. Dilated cardiomyopathy

Answer: (C)

Takotsubo cardiomyopathy, also known as stress-induced or “broken heart” syndrome, is the pattern this vignette points to. The key clues are a recent stress trigger, occurring in a postmenopausal woman, and the echocardiographic finding of left ventricular ballooning. In Takotsubo, there is transient systolic dysfunction of the LV that typically affects the apical or mid-ventricular segments, producing apical ballooning with relatively preserved basal contraction. This imaging pattern often mimics an acute coronary syndrome because of chest pain and ECG/troponin changes, but the coronary arteries are typically without obstructive disease, and heart function usually returns to normal within days to weeks.

In contrast, an aortic dissection presents with sudden, severe chest pain and often differing blood pressures or pulse deficits and is diagnosed by imaging showing dissection of the aorta. An acute myocardial infarction shows wall-motion abnormalities that align with a specific coronary territory due to an occluded plaque, and tends to be persistent unless reperfusion occurs. Dilated cardiomyopathy features diffuse, not regional, LV dilation and dysfunction, and it is not characteristically precipitated by a recent stressor.