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: : acute, stress-induced; , reversible dysfunction of the left ventricle that can mimic acute coronary syndrome
- 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.
- 90% of affected individuals are postmenopausal women. 
- More common in patients with preexisting mental illness 
Epidemiological data refers to the US, unless otherwise specified.
- Triggers 
- Pathophysiology: Emotional/physical stress → activation of the sympathetic nervous system; → massive catecholamine discharge; → cardiotoxicity, multivessel spasms, and dysfunction → myocardial stunning
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. 
- Check ECG, cardiac biomarkers, and bedside TTE (if available).
- Determine the pretest probability of takotsubo cardiomyopathy and ACS (using patient risk factors and diagnostic criteria).
- Check cardiac MRI to better characterize myocardial edema.
Revised Mayo Clinic criteria: all of the following must be present 
- Presence of cardiac ischemia
- Presence of LV dysfunction (with or without apical involvement)
- Absence of obstructive coronary disease or acute plaque rupture (typically requires angiography)
- Absence of myocarditis or pheochromocytoma
|InterTAK diagnostic score |
|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|
Laboratory studies 
- ST elevations (most common finding), typically in the precordial leads
- ST depressions are uncommon (< 10% of cases).
- Diffuse T-wave inversions
- Prolonged QT interval
Echocardiography (TTE) 
- 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 
- LVOT obstruction may be present (up to 25% of cases) 
- Coronary angiography (with ventriculography) 
Cardiac MRI 
- Suggestive findings
- Possible additional findings
- Coronary CT angiography: consider as an alternative for stable patients with contraindications to cMRI to exclude high-grade coronary stenosis 
- Acute coronary syndrome
- Acute myocarditis
- See differential diagnosis of chest pain.
- See cardiomyopathy.
The differential diagnoses listed here are not exhaustive.
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 
- Heart failure management 
Hemodynamically unstable patients 
No LVOT obstruction 
Inotropic support: Dobutamine and dopamine can be used; however, both can cause tachycardia and worsening of takotsubo cardiomyopathy, and so other agents, e.g., levosimendan, may be preferable. Patients receiving inotropic support should be monitored closely for the development of LVOT. 
- Levosimendan 
- OR milrinone
- Vasopressor support: if inotropes are insufficient 
- Advanced therapies: consider in refractory cases
LVOT obstruction (occurs in up to 25% of cases) 
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.
- IV fluids: may improve LV systolic function
- Beta blocker: Use of a short-acting, low-dose beta blocker (if tolerated) may be helpful to relieve LVOT obstruction but should be used with caution in patients with hypotension. 
- Vasopressor support: in cases of shock
- Advanced therapies: consider in refractory cases
- The following therapies should be avoided:
Additional considerations for all patients 
- Empiric treatment of ACS: Consider until ACS is ruled out (see “Treatment” in acute coronary syndrome and “Diagnostic criteria” above).
- VTE prophylaxis: consider especially in patients with reduced apical motion and all unstable patients 
- Prevention of arrhythmia
- Chronic therapy
- Identify and treat the underlying cause: e.g., SSRI therapy for depression
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 
- Recurrence rate: 2–4% per year 
- In-hospital mortality: up to 5% 
- Evaluate the need for urgent coronary angiography.
- Check troponin, BNP.
- Cardiology consult
- Echocardiogram and/or cMRI
- VTE prophylaxis
- Continuous telemetry for 48 hours
- Monitor QTc. 
- Identify and treat the underlying cause.
Hemodynamically stable patients
- Supportive care
- Treat systolic heart failure (e.g., diuresis, low-dose beta blocker, ACE inhibitor/ARB).