Electrocardiographic features of Takotsubo syndrome with right ventricular pacing

Takotsubo syndrome (TTS) is an acute reversible myocardial injury with typical electrocardiographic (ECG) features, which is often obscured by right ventricular pacing (RVP) and causes diagnostic challenges. Accurate ECG interpretation in paced patients is critical to avoid mismanagement.

To systematically summarize the ECG features of TTS in patients with RVP and clarify how these features aid in differentiating TTS from acute coronary syndrome (ACS).

We conducted a PRISMA-compliant systematic review (PROSPERO: CRD420251145162) searching PubMed, Embase, and Web of Science (1990-July 2025).

Of 53 screened studies, 15 cases (14 publications, 2006-2025) were included. Patients were 86.7% female (mean age 71 years). Key ECG findings: All evaluable cases lacked ST-segment depression or abnormal Q waves; 8 had ST-segment elevation (predominantly in precordial leads V2-V5), 10 had concordant T-wave inversion, 12 had corrected QT interval prolongation, 4 showed QRS amplitude attenuation (all post-pacemaker TTS [PP-TTS]), and 2 experienced ventricular tachycardia. Subgroup analysis revealed that T-wave inversion was more frequent in patients with a pacemaker history (pH-TTS, 100%) than in PP-TTS (44.4%), with statistical significance (P = 0.012).

TTS with RVP exhibits distinct ECG features (e.g., concordant T-wave inversion, no ST-segment depression/abnormal Q waves) that distinguish it from ACS. Clinicians should use these features to diagnose TTS in paced patients, avoiding unnecessary invasive procedures.