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Purpose: The underlying diagnosis in patients with acute coronary syndrome (ACS) and unobstructed coronary arteries remains a diagnostic challenge. We analyzed the value of magnetic resonance imaging (MRI) in this clinical setting.Methods: A total of 213 patients with ACS and unobstructed coronary arteries underwent MRI within a median of 2 days after initial presentation. Clinical, laboratory, and MRI data were analyzed. A consensus diagnosis was established for each case by an independent panel after reviewing the individual clinical, laboratory, and MRI data. Standardized interviews to determine patient outcomes were carried out after a median follow-up of 24 months. Clinical events were defined as a composite of death, stroke, myocardial infarction or recurrence of Takotsubo syndrome (TTS), new onset of heart failure with a left ventricular ejection fraction (LVEF) <30%, and occurrence of a new left ventricular thrombus formation.Results: Final diagnoses included acute myocardial infarction (AMI) (40%), acute myocarditis (24%) and TTS (33%). In 3% of patients, nonspecific findings lead to an indeterminate diagnosis. Patients with TTS showed a significantly impaired LVEF during the index event (50% vs. 60% in AMI and 60% in myocarditis, P = 0.001). The extent of myocardial edema was most pronounced in patients with TTS (13.4%±11.4 vs. 4.6%±7.9 in AMI and 1.8%±2.7 in myocarditis, P < 0.001). TTS patients had the highest event rate (16.9%).Conclusion: Our study emphasizes the diagnostic utility of timely MRI in patients with ACS and unobstructed coronary arteries. We found a high prevalence of TTS patients, who had poorer outcomes compared with patients with a final diagnosis of AMI or myocarditis. [ABSTRACT FROM AUTHOR]

Standard pharmacological therapy in Takotsubo syndrome (TTS) is still debated and there is a lack of prospective data. In their recent work in BMC Cardiovascular Disorders Abanador-Kamper et al. found that stroke in TTS has an event rate of 2.8% after 30 days and 4.2% after 12 months and they question which patients need oral anticoagulation. According to our clinical data, TTS patients with LV thrombi may be at high risk of stroke. These patients are characterized by apical ballooning pattern, high prevalence of ST-elevation and higher troponin I levels. We have recently proposed a therapeutic algorithm for oral anticoagulation in TTS. In case of apical ballooning pattern and increased admission levels of troponin-I (> 10 ng/mL), oral anticoagulation should be considered, while in case of midventricular/basal ballooning or apical ballooning associated with troponin-I levels < 10 ng/ml, oral anticoagulation should not be considered. A simple combination of echocardiographic parameters (apical ballooning pattern),ECG data (ST-elevation at admission and persistent after 72 h) and laboratory values (troponin serum levels) could be useful for an appropriate therapeutic management of oral anticoagulation in TTS. [ABSTRACT FROM AUTHOR]