Letter to the Editor The Tako-Tsubo syndrome: No evidence of peripheral endothelial or microvascular dysfunction

Dear sir, The Tako-Tsubo syndrome or left ventricular apical ballooning syndrome is a recently described condition characterized by precordial pain, ST-segment elevation and T wave abnormalities in the left precordial leads of the ECG as well as akinesia of all apical segments of the left ventricle in the absence of coronary artery disease at angiography [1]. While its pathogenesis remains incompletely understood, the Tako-Tsubo syndrome has been proposed to be determined by catecholamine-induced endothelial dysfunction and subsequent impaired microvascular reactivity at the level of the mid and apical segments of the left ventricle [2]. We report a case of a 73-years-old woman with history of hypertension who was admitted to the Emergency Department for oppressive chest pain radiated to the right arm and the back. Upon admission, the patient showed high blood pressure levels (160/110 mmHg); her ECG showed sinus rhythm and Twave inversion in leads II, III, aVF, V5 and V6. Troponin T was 0.39 ng/ml (reference range, b0.06 ng/ml) and increased to 0.61 ng/ml 6 h later, when a minor elevation of CPK and CPK-MB was also observed. Therapy with lowmolecular weight heparin and double antiplatelet agents (aspirin 100 mg+clopidogrel 50 mg) was started. The day after, the patient was asymptomatic but ECG showed a 1– 2 mm STsegment elevation in leads V2, V3 and deep Twave inversioninleads I,II,III,AVFandV4–V6.Echocardiogram revealed hypokinesia of the left ventricular apex and mid segment of the septum with ejection fraction of 50%. At this point, coronary angiography was performed, which showed patent epicardial coronary arteries. The left anterior descending coronary artery was particularly developed and its mid segment presented an intramural course. Left ventriculography showed akinesia of the entire apex as well as hyperkinesia of the basal segments with systolic apical ballooning (Fig. 1). Endothelial function of peripheral