From the Guidelines
Left ventricular apical dyskinesia on transthoracic echocardiography (TTE) is most commonly caused by Takotsubo cardiomyopathy (stress-induced cardiomyopathy), which typically presents with transient apical ballooning following emotional or physical stress, as evident in the 2018 international expert consensus document on Takotsubo syndrome 1.
Common Causes of Left Ventricular Apical Dyskinesia
Other important causes include:
- Coronary artery disease, particularly anterior myocardial infarction involving the left anterior descending artery
- Left ventricular aneurysms, resulting from prior myocardial infarction with subsequent remodeling
- Myocarditis
- Hypertrophic cardiomyopathy with apical variant
- Infiltrative cardiomyopathies such as amyloidosis or sarcoidosis
- Congenital abnormalities like left ventricular non-compaction
Diagnostic Approach
When evaluating apical dyskinesia, it's essential to correlate findings with clinical history, electrocardiogram changes, cardiac biomarkers, and potentially other imaging modalities like cardiac MRI or coronary angiography to determine the underlying etiology, as treatment approaches differ significantly based on the cause, as supported by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1.
Key Considerations
- The likelihood of abnormal findings increases when TTE is performed selectively among higher risk patients, such as those with electrocardiographic Q waves or heart failure symptoms, complex ventricular arrhythmias, or a heart murmur 1
- Advanced echocardiographic techniques such as speckle-tracking imaging can reveal a paradoxical (dyskinetic) positive longitudinal systolic strain of biventricular mid-apical segments, aiding in the diagnosis of Takotsubo cardiomyopathy 1
From the Research
Common Causes of Left Ventricular Apical Dyskinesia
- Left ventricular apical dyskinesia can be caused by various factors, including acute myocardial infarction due to isolated left circumflex coronary artery stenosis 2
- Takotsubo syndrome, also known as transient apical dyskinesia syndrome, is a rare entity that can cause left ventricular apical dyskinesia, often triggered by severe emotional stress 3
- Other potential causes of left ventricular apical dyskinesia include regional dyskinesia versus akinesia in acute myocardial infarction 4 and left ventricular transient dyskinesias (LVTD) 5
Diagnostic Criteria
- The diagnosis of left ventricular apical dyskinesia can be made using transthoracic echocardiography (TTE), with the use of outward displacement of the soft tissue between the apex and the chest wall as a sign of apical displacement 6
- Cardiac magnetic resonance imaging (MRI) can be used to validate the presence of apical dyskinesis 6
- Clinical diagnostic criteria have been proposed for Takotsubo syndrome, although they are still controversial 3
Prognostic Importance
- The presence of dyskinesia has been found to have no independent long-term prognostic importance, but it may have prognostic importance for the first 30 days after acute myocardial infarction 4
- Left ventricular transient dyskinesias (LVTD) have been found to represent a decreased risk of events when compared with classic non-ST-segment acute coronary syndrome 5