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A 69–year–old woman suffering from hypercholesterolemia, GERD, was admitted to our department for anterior ST elevation myocardial infarction and was treated with primary PCI and DES on the mid–distal LAD. Dual antiplatelet therapy (DAPT) with ticagrelor and cardioaspirin was started. The pre–discharge echocardiogram (echo) showed the presence of left ventricular thrombus (LVT) and anticoagulant therapy (enoxaparin and warfarin) was started. On the 9th day the patient complained abdominal pain with onset of chills and hyperthermia and was suspected an uro–septic fever. The day after a mass appeared on the right abdominal wall at the site of the enoxaparin injection and abdominal contrast CT showed a mass of inhomogeneous density, actively supplied by the inferior epigastric artery and its terminal branches, indicative of hematoma of the abdominal rectus muscle. Anticoagulant therapy was suspended. Interventional radiologists in consideration of clinical stability and stable Hb value and the absence of the signs of active arterial bleeding on CT have not indicated an urgent endovascular treatment and DAPT with clopidogrel and cardioaspirin was continued. After V days, echo showed persistent pedunculated and mobile LVT and aspirin was therefore suspended and anticoagulant therapy was reintroduced with fondaparinux 2.5 mg daily. After two days, considering the stability of hematoma dimensions and the Hb values but the persistence of the extremely floating LVT, fondaparinux was increased at dose of 5 mg daily. In the following days, echo showed LVT reworking until its complete disappearance. On the 32th day blood test showed significant reduction in Hb values and a contrast CT showed an increase in size of the hematoma and resumption of micro bleeding. Fondaparinux was stopped and the patient was transferred to the interventional radiology center. Angiography highlights point–like spreads of extravascular contrast from branches of the inferior epigastric artery and branches of the external circumflex iliac artery. Embolization was performed. After a close monitoring of the hemoglobin values and of the echo which showed no LVT and recovery of LV function, in consideration of her thrombotic and hemorragic risks, she was discharged with DAPT with clopidogrel and low dose of aspirin. Abdominal wall hematoma may be a rare complication of subcutaneous enoxaparin therapy especially in STEMI patients undergoing also a DAPT therapy.

Introduction Tako–Tsubo Syndrome (“TTS”) is a cardiomyopathy characterized by an acute reversible left ventricular dysfunction, mainly triggered by emotional or physical stress. Several variants have been reported, including reverse TTS, characterized by hypokinesia of basal segments and hyperkinesis of the apical ones. TTS has a clinical presentation similar to acute coronary syndrome but without evidence of obstructive coronary artery disease. A surprising association between TTS and cancer arose out of recent studies. Case Presentation 74–year–old patient got to the emergency room of our hospital for the appearance, apparently in the health, in the absence of physical or emotional stress of oppressive chest pain. On the ECG, there was evidence of ST–segment elevation in inferior leads, for which urgent coronary angiography was performed. It did not show significant stenotic lesions nor evidence of elevated troponin values. The Echocardiogram showed hypokinesia of the basal segments and hyperkinesis of the mid–apical ones, with EF 40%. In the following days, the patient performed MRI–heart with detection of LGE of the intramyocardial type (non–ischemic pattern) in correspondence with the inferior wall in the medioventricular area. During hospitalization on routine chest x–ray, hypodiaphanous image was found in the left apex for which an HR CT scan of the chest was performed which a lesion in the left apical lung area with spiculated margins of a heteroplastic nature, associated with multiple bilateral lesions suggestive of secondaryism. Therefore, the patient was taken over by the Oncology service. Conclusions Such case confirms the association between TTS and occult cancer. In the absence of obvious physical or emotional stress that may explain the onset of TTS, it is important to research for any silent neoplastic pathology. The literature shows that the prevalence of malignant diseases is high in patients with TTS. Recent studies have pinpointed the activation of the sympathetic nervous system promotes cardiac inflammation by upregulating ICAM–1 and the expression of p53. Furthermore, inflammation can lead to the activation of p38 MAP Kinase, thus contributing to myocardial stunning. The specific role of inflammation as a cofactor of adrenaline–induced stunning deserves further investigation in the specific context of malignant tumors, which are frequently associated with an enhanced inflammatory state.

Patient Presentation A 52 y/o female with history of arterial hypertension, diabetes mellitus, Bentall‘s previous intervention, presented to emergency department complaining dyspnea and oppressive chest pain which arose during celebrations for Italy‘s victory at the European soccer championship. According to increase in cardiac troponin level and ECG findings of subendocardial ischemia she was admitted to our Coronary Care Unit for acute coronary syndrome suspicious. Management transthoracic echocardiography (TTE) showed reduced left ventricle ejection fraction (LVEF 37%) with apical and left ventricle medium segments akinesis associated with basal segments hyperkinesis with typical apical ballooning aspect. According to these findings, Takotsubo syndrome (TTS) suspicious overtook acute coronary syndrome. Despite low probability of coronary disease, she underwent coronary angiography which was normal. Eight days later, TTE showed completely recovery with normal LVEF. At the routine blood test we found not known hyperthyroidism without detectable antibodies; thyroid ultrasound showed some cystic lesion without any nodule. Thyroid scintigraphy was normal. Antithyroid medications were started and one month later complete normalization of thyroid hormones occurred. The patient was event–free after correction of the hyperthyroidism. Discussion “Happy heart syndrome” (HHS) is a TTS triggered by deep happiness and positive emotions. TTS is an usual form of acute cardiomyopathy characterized by reversible left ventricle apical ballooning which occurs in the absence of significant coronary artery disease. Although the exact cause of TTC remains unknown, several pathogenetic mechanisms have been suggested. Catecholamines seem to play a central role and we know that thyroid hormones interact with sympathetic nervous system so that hyperthyroidism is associated with hypersensitivity to catecholamines. Tako–Tsubo syndrome is usually triggered by negative stressors such as fright, grief, rage, other diseases. The role of positive emotions is not well known neither described. We assume that the mechanisms are similar but triggered by different emotions. HHS seems to be caused by pleasant emotional life events such as birthday party, son’s wedding and so many others. Both positive and negative life events could trigger TTS, nevertheless negative life events trigger TTS in almost 95% of the cases, so “broken hearts” are more frequent than “happy hearts”.