Diagnostic challenges of Takotsubo syndrome in the context of hypertrophic obstructive cardiomyopathy phenocopy

The diagnosis of Takotsubo syndrome may be challenging in daily clinical practice. Our patient presented with an initial diagnosis of acute anterolateral ST elevation myocardial infarction, while coronary angiography showed non-obstructive coronary arteries. Transthoracic echocardiography raised the suspicion of hypertrophic obstructive cardiomyopathy (HOCM) and Takotsubo syndrome. In such clinical presentations, cardiac MRI (cMRI) plays a crucial role in differential diagnosis as part of a multimodality imaging approach. For our patient, serial cMRI studies helped to establish the diagnosis of Takotsubo syndrome during the index presentation and confirmed it retrospectively; the presence of transient hypertrophic cardiomyopathy phenocopy and left ventricular outflow tract obstruction (LVOTO) was partially due to transient oedema in the active phase of the condition. In addition, cMRI proved to be a key modality for excluding HOCM as a potential alternative cause of the dynamic LVOTO. With the implementation of complex guideline-directed medical therapy, the patient improved to the heart failure with improved ejection fraction category with a remarkable improvement in clinical status.