Myocardium

Takotsubo Cardiomyopathy

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Takotsubo Cardiomyopathy, Stress Cardiomyopathy, Broken Heart Syndrome, Stress Induced Cardiomyopathy

  • See Also
  1. MINOCA
  2. Cardiomyopathy
  • Definitions
  1. Takotsubo Cardiomyopathy
    1. Abrupt onset Left Ventricular Systolic Dysfunction as a response to severe emotional or physiologic stress
  • Epidemiology
  1. Prevalence: 0.02% of hospitalized patients
  2. Ages 50 to 70 most commonly affected
  3. Primarily in women (95% of cases)
  4. Accounts for 1-2% of presumed STEMI cases
  • History
  1. Initially described in Japan (1990)
  2. Takotsubo is Japanese for a ceramic octopus trap (which resembles the heart on Echocardiogram)
  • Pathophysiology
  1. Postulated cause as Catecholamine surge that results in heart Muscle injury and a drop in contractility
  2. Transient with often a full recovery without significant residual Cardiomyopathy by 2 weeks
  • Risk Factors
  1. Major stressors (85%-89% report a stressful event in the preceding 12 hours)
  2. Stress examples
    1. Emotional stressors (e.g. fear, grief, anger)
    2. Physical stressors (e.g. Cerebrovascular Accident)
    3. General Surgery
    4. Chemotherapy
    5. Exogenous Catecholamines such as beta Agonists (e.g. Albuterol, Phenylephrine)
  • Symptoms
  1. Mimics Acute Coronary Syndrome
  2. Chest Pain
  3. Shortness of Breath
  • Signs
  1. May present with Cardiogenic Shock or lethal Arrhythmia (e.g. VT/VF, PEA)
  • Labs
  1. Serum Troponin
    1. Frequently increased
  • Diagnostics
  1. Electrocardiogram
    1. May mimic ST Elevation Myocardial Infarction
    2. Deep T Wave Inversions and ST Depression
    3. May demonstrate contiguous lead ST Elevation with reciprocal changes
      1. Frequently affects the anterior distribution and to a lesser extent inferior distribution
  2. Echocardiogram
    1. Acute, severe Systolic Dysfunction (with ejection fraction dropping from normal to <25-35%)
    2. Echocardiogram demonstrates reduced contractility not explained by single vessel disease
    3. May demonstrate apical ballooning of the left ventricle
    4. Akinetic apex
    5. Heart assumes elongated shape
      1. Named Takotsubo for the affected heart's similar appearance to a Japanese octopus trap
  3. Angiogram
    1. No occlusive vascular disease identified to explain the event
  • Management
  1. Supportive care
  2. Start by treating as Acute Coronary Syndrome and exclude STEMI
  3. Manage Arrhythmias as needed
  4. Manage Cardiogenic Shock and Acute Pulmonary Edema
    1. See Cardiogenic Shock for emergent management
    2. Beta Blockers and ACE Inhibitors are commonly used for Takotsubo Cardiomyopathy
    3. Consider Diuretics
    4. Anticoagulation may be considered (if decreased left ventricle wall motion)
    5. Consider Endotracheal Intubation
    6. Consider Intra-aortic balloon pump
  • Prognosis
  1. Initial aggressive management is critical for good prognosis
  2. Ejection Fraction returns to normal (at least >50%) in nearly all cases (100% in the Sharkey study)
    1. Typically normalizes after first month
  3. Mortality 2% during hospitalization
  4. Recurrence in 5-6%
  • References
  1. Hochman and Patel in Herbert (2015) EM:Rap 15(1): 4-6
  2. Brieler (2017) Am Fam Physician 96(10):640-6 [PubMed]
  3. Sharkey (2010) J Am Coll Cardiol 55(4): 333-41 [PubMed]