• Yong Wang, Wei Guo, and Jianliang Ma.
• Department of Cardiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine.
• Medicine (Baltimore). 2019 Mar 1; 98 (9): e14677.

RationaleThe clinical features of Takotsubo cardiomyopathy largely overlap with those of acute myocardial infarction, especially in the presence of ST-segment elevation on the initial electrocardiogram. Giant R wave syndrome has mainly been observed in the hyperacute phase of acute myocardial infarction.Patient ConcernsIn this study, we report a unique case of Takotsubo cardiomyopathy that caused giant R wave syndrome.DiagnosisA 71-year-old woman was transferred to hospital with new onset chest pain. An initial electrocardiogram showed ST-segment elevation in the inferior wall and anterior wall leads. Her initial cardiac troponin I levels were elevated. Acute myocardial infarction was suspected and the patient underwent emergent cardiac catheterization. A coronary angiography showed no overt stenosis in the coronary artery. After 2 hours, her chest pain disappeared and an electrocardiogram revealed that the ST segment had decreased markedly. However, on day 3, an electrocardiogram of the V1-V6 leads revealed the formation of giant R wave syndrome: giant R waves merging with the markedly elevated ST segments and the obliteration of S waves. Cardiac echocardiography showed hypokinetic apical mid-segments and hyperkinetic basal segments of the left ventricle, low left ventricular ejection (42%), and enlargement of the left ventricle. On the basis of these findings, the patient was diagnosed with early recurrent Takotsubo cardiomyopathy.InterventionsThe patient has been treated by levosimendan and furosemide to improve cardiac function before leaving the hospital. After discharge, she was treated with a beta blocker.OutcomesThe patient was discharged 2 weeks later in stable condition without chest pain. One year later, during her follow-up, a repeat echocardiogram and ECG showed normal findings.LessonsTo the best of our knowledge, this is the first report of giant R wave syndrome on electrocardiogram following Takotsubo cardiomyopathy. Takotsubo cardiomyopathy, especially presenting with giant R wave syndrome on electrocardiogram, remains a challenging condition given its similarity to acute myocardial infarction in its early phase.

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