• Clinical science
  • Clinician

Takotsubo cardiomyopathy (Stress-induced cardiomyopathy)

Summary

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, refers to acute, stress-induced, reversible dysfunction of the left ventricle. It is an uncommon but clinically significant cause of chest pain that can mimic acute coronary syndrome (ACS). Typically triggered by an extreme emotional stressor or severe illness, it is typically characterized by ballooning of the left ventricular wall, which can lead to chest pain and heart failure. While most cases fully resolve within a couple of weeks, patients can become critically ill, particularly if the disease causes left ventricular outflow tract obstruction (LVOT obstruction). As symptoms overlap with those seen in acute coronary syndrome, this condition should be excluded. See also cardiomyopathy for information on other cardiomyopathies.

Definition

  • Definition: : acute, stress-induced; , reversible dysfunction of the left ventricle that can mimic acute coronary syndrome
  • Classification [1]
    • Primary form: Symptoms have led the patient to seek medical attention.
    • Secondary form : The patient is already seriously ill with another condition, meaning that the presentation may be more insidious.

Epidemiology

  • 90% of affected individuals are postmenopausal women. [2]
  • More common in patients with preexisting mental illness [3]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • Triggers [2][3]
    • Intense emotional stress
      • The stress is usually negative (i.e., “broken heart syndrome”)
      • Less common: strong, positive emotions (i.e., “happy heart syndrome”)
    • Severe illness
    • Drugs
  • Pathophysiology: Emotional/physical stress → activation of the sympathetic nervous system; massive catecholamine discharge; → cardiotoxicity, multivessel spasms, and dysfunction myocardial stunning

Clinical features

Symptoms overlap with those seen in acute coronary syndrome (see “Clinical features” in acute coronary syndrome) and are characteristically preceded by a stressful event. [2][1]

Diagnostics

The diagnosis of takotsubo cardiomyopathy requires left ventricle regional wall motion abnormalities (typically reversible) that extend beyond a single coronary artery distribution in the absence of obstructive coronary artery disease. It is extremely difficult to distinguish between takotsubo cardiomyopathy and acute coronary syndrome (ACS) on the basis of ECG and laboratory test findings alone; emergency coronary angiography is usually required to rule out ACS. [2][1]

Approach

Diagnostic criteria

Several diagnostic criteria are used to establish a diagnosis of stress-induced cardiomyopathy, including the revised Mayo Clinic criteria and the InterTAK diagnostic score.

  • Revised Mayo Clinic criteria: all of the following must be present [1][4]
    • Presence of cardiac ischemia
      • New ECG abnormalities: ST-segment elevation and/or T-wave inversions
      • Elevation in serum troponin
    • Presence of LV dysfunction (with or without apical involvement)
      • Transient hypokinesis, dyskinesis, or akinesis of the left ventricular midsegments
      • Wall motion abnormalities extend past a single coronary artery vascular distribution.
      • A stressful trigger is often present.
    • Absence of obstructive coronary disease or acute plaque rupture (typically requires angiography)
    • Absence of myocarditis or pheochromocytoma
InterTAK diagnostic score [5]
Variables Points assigned
Female sex 25
Emotional stress 24
Physical stress 13
Absence of ST depressions on ECG 12
Acute, former, or chronic psychiatric disorder 11
Acute, former, or chronic neurological disorder 9
Prolonged QTc interval 6

Interpretation

Laboratory studies [1][2]

ECG [2]

ECG is abnormal in > 95% of patients with takotsubo cardiomyopathy and usually shows ischemic changes. [1]

Imaging

  • Echocardiography (TTE) [6]
    • Indications: all patients suspected of having takotsubo cardiomyopathy
    • Supportive findings
      • LVEF
      • Global LV dyskinesis involving the apex (most common)
      • Regional wall motion abnormalities
        • Apical left ventricular ballooning (not always present)
        • More rarely, midventricular ballooning (10–20% of cases) or basal ballooning (< 5% of cases) may be present [1]
      • LVOT obstruction may be present (up to 25% of cases) [1]
  • Coronary angiography (with ventriculography) [2]
  • Cardiac MRI [7][8][1]
    • Indications
    • Suggestive findings
      • Similar to findings in TTE
      • Transmural edema along the areas of wall motion abnormalities
      • Myocardial scarring
    • Possible additional findings
  • Coronary CT angiography: consider as an alternative for stable patients with contraindications to cMRI to exclude high-grade coronary stenosis [1]

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

Treatment is mostly symptomatic and consists of supportive care and treatment of complications and comorbidities (e.g., acute heart failure, arrhythmias). It is critical to determine if LVOT obstruction (which is typically accompanied by mitral regurgitation) is present because inotropic support in these patients can precipitate worsening cardiac function and lead to cardiogenic shock. Consider empiric treatment for acute coronary syndrome until it can be ruled out. All patients should be admitted to the hospital for at least 48 hours of continuous telemetry.

Hemodynamically stable patients [1][9]

Hemodynamically unstable patients [1][9]

No LVOT obstruction [1]

LVOT obstruction (occurs in up to 25% of cases) [1]

LVOT obstruction further impairs LV systolic function and can be very difficult to treat. Inotropic support should be avoided, as this can precipitate cardiogenic shock in patients with LVOT obstruction.

Avoid inotropes, as they can worsen LVOT obstruction and precipitate cardiogenic shock.

Additional considerations for all patients [9][1]

Prognosis

Although most patients recover within days to weeks, relapses are not uncommon and in-hospital deaths occur especially in patients with complications leading to cardiogenic shock.

  • Recovery: within 1–2 weeks in most cases [1]
  • Recurrence rate: 2–4% per year [1]
  • In-hospital mortality: up to 5% [1]

Acute management checklist

All patients

Hemodynamically stable patients

Hemodynamically unstable patients

  • Transfer to ICU.
  • Determine whether there is LVOT obstruction.
  • Deteriorating patients: Consider mechanical circulatory support.

Prevention

  • Avoid triggers of physical and/or emotional stress.
  • Consider chronic beta blocker and/or ACE inhibitor/ARB therapy. [9][1]
  • Consider assessment (and referral to treatment) for mental health comorbidities. [1]
  • 1. Medina de Chazal H, Del Buono MG, Keyser-Marcus L, et al. Stress Cardiomyopathy Diagnosis and Treatment. J Am Coll Cardiol. 2018; 72(16): pp. 1955–1971. doi: 10.1016/j.jacc.2018.07.072.
  • 2. Pelliccia F, Kaski JC, Crea F, Camici PG. Pathophysiology of Takotsubo Syndrome. Circulation. 2017; 135(24): pp. 2426–2441. doi: 10.1161/circulationaha.116.027121.
  • 3. Ghadri J-R, Wittstein IS, Prasad A, et al. International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology. Eur Heart J. 2018; 39(22): pp. 2032–2046. doi: 10.1093/eurheartj/ehy076.
  • 4. Madhavan M, Prasad A. Proposed Mayo Clinic criteria for the diagnosis of Tako-Tsubo cardiomyopathy and long-term prognosis. Herz. 2010; 35(4): pp. 240–244. doi: 10.1007/s00059-010-3339-x.
  • 5. Ghadri JR, Cammann VL, Jurisic S, et al. A novel clinical score (InterTAK Diagnostic Score) to differentiate takotsubo syndrome from acute coronary syndrome: results from the International Takotsubo Registry. European Journal of Heart Failure. 2016; 19(8): pp. 1036–1042. doi: 10.1002/ejhf.683.
  • 6. Brenner ZR, Powers J. Takotsubo cardiomyopathy. Heart Lung. 2008; 37(1): pp. 1–7. doi: 10.1016/j.hrtlng.2006.12.003.
  • 7. Bratis K. Cardiac Magnetic Resonance in Takotsubo Syndrome. Eur Cardiol. 2017; 12(1): p. 58. doi: 10.15420/ecr.2017:7:2.
  • 8. Kohan AA, Levy Yeyati E, De Stefano L, et al. Usefulness of MRI in takotsubo cardiomyopathy: a review of the literature. Cardiovasc Diagn Ther. 2014; 4(2): pp. 138–46. doi: 10.3978/j.issn.2223-3652.2013.10.03.
  • 9. Komamura K. Takotsubo cardiomyopathy: Pathophysiology, diagnosis and treatment. World J Cardiol. 2014; 6(7): p. 602. doi: 10.4330/wjc.v6.i7.602.
  • 10. Nieminen MS, Fruhwald S, Heunks LM, et al. Levosimendan: current data, clinical use and future development. Heart Lung Vessel. 2013; 5(4): pp. 227–45. pmid: 24364017.
  • 11. Antonini M, Stazi GV, Cirasa MT, Garotto G, Frustaci A. Efficacy of levosimendan in Takotsubo-related cardiogenic shock. Acta Anaesthesiol Scand. 2010; 54(1): pp. 119–120. doi: 10.1111/j.1399-6576.2009.02105.x.
  • 12. Isogai T, Matsui H, Tanaka H, Fushimi K, Yasunaga H. Early β-blocker use and in-hospital mortality in patients with Takotsubo cardiomyopathy. Heart. 2016; 102(13): pp. 1029–1035. doi: 10.1136/heartjnl-2015-308712.
  • 13. Santoro F, Ieva R, Ferraretti A, et al. Hemodynamic Effects, Safety, and Feasibility of Intravenous Esmolol Infusion During Takotsubo Cardiomyopathy With Left Ventricular Outflow Tract Obstruction: Results From A Multicenter Registry. Cardiovasc Ther. 2016; 34(3): pp. 161–166. doi: 10.1111/1755-5922.12182.
  • 14. Yoshioka T, Hashimoto A, Tsuchihashi K, et al. Clinical implications of midventricular obstruction and intravenous propranolol use in transient left ventricular apical ballooning (Tako-tsubo cardiomyopathy). Am Heart J. 2008; 155(3): pp. 526.e1–526.e7. doi: 10.1016/j.ahj.2007.10.042.
  • 15. Migliore F, Bilato C, Isabella G, Iliceto S, Tarantini G. Haemodynamic effects of acute intravenous metoprolol in apical ballooning syndrome with dynamic left ventricular outflow tract obstruction. European Journal of Heart Failure. 2010; 12(3): pp. 305–308. doi: 10.1093/eurjhf/hfp205.
  • 16. Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo Cardiomyopathy. Circulation. 2008; 118(25): pp. 2754–2762. doi: 10.1161/circulationaha.108.767012.
  • Ghadri J-R, Wittstein IS, Prasad A, et al. International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management. Eur Heart J. 2018; 39(22): pp. 2047–2062. doi: 10.1093/eurheartj/ehy077.
  • Mrozek S, Srairi M, Marhar F, et al. Successful treatment of inverted Takotsubo cardiomyopathy after severe traumatic brain injury with milrinone after dobutamine failure. Heart & Lung. 2016; 45(5): pp. 406–408. doi: 10.1016/j.hrtlng.2016.06.007.
last updated 06/11/2020
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