Bizarre T-wave Inversions in a Patient without Chest Pain

This was sent by a recent ultrasound fellow, asking for my ECG diagnosis.

He stated that it is "an acute change from previous" in an elderly smoker with hypertension, syncope, and abdominal pain.

First, there is some lead placement problem with V2, but I'm not sure exactly where it belongs!
There is ST elevation in I, II, III, aVF, V2, V3, V4, V5, and V6.
There is bizarre T-wave inversion with very long QT in all these leads
What is this?

My response:
"These are typical of Takotsubo or CNS catastrophe.
Obviously it is clinically not a CNS catastrophe, so it must be Takotsubo.

You must have done an echo?

Apical ballooning?"

His answer:

"It was Takotsubo!  Sadly I did not perform my own echo.  It was a busy shift, fewer US machines are available here, so I could not find one in that moment.  Cards came to see the patient and brought their machine down, and he had clear apical ballooning and the cath lab was activated in the middle of the night (a little begrudgingly).  The angiogram was negative."

Comment

Notice that I did not even put ACS on my differential?  These ECGs, in my experience, are not seen  in ACS.  

However, there are morphologies of Takotsubo that cannot be distinguished from STEMI.  See below.

Here are some examples:

1.

Takotsubo Stress Cardiomyopathy that mimics LAD occlusion
Cath was clean.

 2.

Central Nervous System T-waves. This one is called:

"Spiked Helmet Sign"

3.

Takotsubo
Typical Takotsubo, very unlikely to be ACS because of extremely long QT
Presented with altered mental status, hypotension, and mild chest discomfort
Peak trop 0.15
Angiogram is not necessary if there is apical ballooning.

4.

Takotsubo
This looks like and infero-posterior STEMI, but the QT is bizarrely long.
In the right clinical situation, this could actually be STEMI (not very typical though).
This patient presented with altered mental status and seizure, so the diagnosis of Takotsubo can be made without angiography or even echo.

5. Diffuse ST Elevation with Apical Ballooning: is it Takotsubo Stress Cardiomyopathy?

33 yo male with 2 days of chest pain

This was an anterior STEMI that had apical ballooning and was wrongly thought to be Takotsubo

Diffuse ST Elevation with Apical Ballooning: is it Takotsubo Stress Cardiomyopathy?

Patient had a presentation of chest pain and this ECG is much more likely to be LAD occlusion of a wraparound (type III) LAD to the inferior wall.  The only reason to think it might be Takotsubo is the apical ballooning on echo, but that is often seen with occlusion of a wraparound LAD. 

LAD Occlusion

6. Chest pain presentation: Takotsubo mimics LAD occlusion

Chest pain presentation: Takotsubo mimics LAD occlusion
Because the presentation is chest pain, an angiogram was done to be certain this is not a wraparound LAD
Cath lab activated, coronaries clean, apical ballooning on echo.