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Takotsubo cardiomyopathy

Last updated: May 6, 2020

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. [1][2]

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. [1][2]

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]
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

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 [1][9]

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

Prevention

  • Avoid triggers of physical and/or emotional stress.
  • Consider chronic beta blocker and/or ACE inhibitor/ARB therapy. [1][9]
  • Consider assessment (and referral to treatment) for mental health comorbidities. [1]

References

  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): p.1955-1971. doi: 10.1016/j.jacc.2018.07.072 . | Open in Read by QxMD
  2. Pelliccia F, Kaski JC, Crea F, Camici PG. Pathophysiology of Takotsubo Syndrome. Circulation. 2017; 135 (24): p.2426-2441. doi: 10.1161/circulationaha.116.027121 . | Open in Read by QxMD
  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): p.2032-2046. doi: 10.1093/eurheartj/ehy076 . | Open in Read by QxMD
  4. Madhavan M, Prasad A. Proposed Mayo Clinic criteria for the diagnosis of Tako-Tsubo cardiomyopathy and long-term prognosis. Herz. 2010; 35 (4): p.240-244. doi: 10.1007/s00059-010-3339-x . | Open in Read by QxMD
  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): p.1036-1042. doi: 10.1002/ejhf.683 . | Open in Read by QxMD
  6. Brenner ZR, Powers J. Takotsubo cardiomyopathy. Heart Lung. 2008; 37 (1): p.1-7. doi: 10.1016/j.hrtlng.2006.12.003 . | Open in Read by QxMD
  7. Bratis K. Cardiac Magnetic Resonance in Takotsubo Syndrome. Eur Cardiol. 2017; 12 (1): p.58. doi: 10.15420/ecr.2017:7:2 . | Open in Read by QxMD
  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): p.138-46. doi: 10.3978/j.issn.2223-3652.2013.10.03 . | Open in Read by QxMD
  9. Komamura K. Takotsubo cardiomyopathy: Pathophysiology, diagnosis and treatment. World J Cardiol. 2014; 6 (7): p.602. doi: 10.4330/wjc.v6.i7.602 . | Open in Read by QxMD
  10. Nieminen MS, Fruhwald S, Heunks LM, et al. Levosimendan: current data, clinical use and future development.. Heart Lung Vessel. 2013; 5 (4): p.227-45.
  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): p.119-120. doi: 10.1111/j.1399-6576.2009.02105.x . | Open in Read by QxMD
  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): p.1029-1035. doi: 10.1136/heartjnl-2015-308712 . | Open in Read by QxMD
  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): p.161-166. doi: 10.1111/1755-5922.12182 . | Open in Read by QxMD
  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): p.526.e1-526.e7. doi: 10.1016/j.ahj.2007.10.042 . | Open in Read by QxMD
  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): p.305-308. doi: 10.1093/eurjhf/hfp205 . | Open in Read by QxMD
  16. Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo Cardiomyopathy. Circulation. 2008; 118 (25): p.2754-2762. doi: 10.1161/circulationaha.108.767012 . | Open in Read by QxMD
  17. 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): p.2047-2062. doi: 10.1093/eurheartj/ehy077 . | Open in Read by QxMD
  18. 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): p.406-408. doi: 10.1016/j.hrtlng.2016.06.007 . | Open in Read by QxMD