Introduction: 10% of patients presenting with angina and ST segment elevation do not, have coronary occlusion. Takotsubo cardiomyopathy is characterized by left ventricular dysfunction and transient abnormal segmental wall motion, associated with typical angina and ST segment elevation, frequently identifying an emotional stress trigger, but without coronary obstruction. There is a controversy on whether Takotsubo cardiomyopathy should be classified as a Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA). Presenting this case has the purpose of underlining the role of multimodal imaging, particularly that of magnetic resonance imaging (MRI) for es-tablishing the etiological diagnosis.

Case presentation: A 43 year old woman, with hyper-tension and recent tuberculous pleural effusion, pre-sents with a first episode of angina at rest, long duration and dyspnea. We mention the absence of an emotio-nal stress trigger. At the admission: hemodynamically stable, but BP= 160/90mmHg, physical examination with normal findings. During hospitalization she re-peats a short episode of angina. Laboratory test results show normal values of CK, CKMB, but a high-sensi-tive troponin rise to a peak of 1124ng/L; NTproBNP= 1331pg/ml; without anemia or inflammation; normal renal function. Electrocardiogram (ECG) shows sinus rhythm with ST segment elevation in V2-V5, avL and poor R wave progression in V1-V3, subsequently with negative T wave in V1-V6, avL; at discharge biphasic T waves in V2-V6. Transthoracic echocardiogram (TTE) at admission re-veals mild left ventricular systolic dysfunction with an estimated left ventricular ejection fraction (LVEF) of 45%, apical ballooning and compensatory basal hyperki-nesia. Coronary angiography found normal epicardial coronary arteries. Left ventriculography showed apical ballooning and akinesia. Subsequent TTE examination reveals LVEF 56%, akinesia in the apical third of the LV, normal right ventricular function and no valvulo-pathy. Cardiac MRI describes on the background of a preserved LVEF(58.07%), preservation of contractility in the basal segments, but with moderate hypokinesia in the apical third of the LV (left ventricle), with apical ballooning and diffuse myocardial edema at the apical third of the LV on T2-weighted sequences; it also re-veals the presence of subendocardial apical septal and transmural apical lateral late gadolinium enhancement, certifying the presence of small areas of myocardial in-farction, without a clear systematization. One month and three months follow-up showed normalization of the ECG and mild hypokinesia in the apical third of the LV, but without apical ballooning.

Conclusions: T he apical ballooning aspect revealed by the ventriculography, echocardiography and MRI associated with the diagnosis of burnout syndrome es-tablished by the psychiatrist plead for Takotsubo car-diomyopathy. However, the presence of subendocardi-al and transmural late gadolinium enhancement, the absence of an emotional trigger and the evolution of the ECG at the beginning made it difficult to rule out MINOCA. The reversibility of the presented elements at the follow-up established the diagnosis of Takotsubo cardiomyopathy. The particularity of the case, given by the confounding findings at the start that made it difficult to determine the etiology of myocardial injury underline the impor-tance of multimodal imaging and that of serial follow-up in establishing the final diagnosis.