What are the indications for anticoagulation in Takotsubo (Stress) cardiomyopathy?

From the Guidelines

Anticoagulation in Takotsubo cardiomyopathy is primarily indicated when left ventricular thrombus is present or when there is severe left ventricular dysfunction with apical akinesis or dyskinesis, as stated in the 2018 international expert consensus document on takotsubo syndrome 1. The indications for anticoagulation in Takotsubo cardiomyopathy can be summarized as follows:

• Presence of left ventricular thrombus
• Severe left ventricular dysfunction with apical akinesis or dyskinesis For patients with documented thrombus, therapeutic anticoagulation with warfarin (target INR 2-3) or a direct oral anticoagulant (DOAC) such as apixaban 5mg twice daily is recommended for at least 3 months or until thrombus resolution and recovery of left ventricular function. In patients with severe apical akinesis without visible thrombus but with ejection fraction less than 35%, prophylactic anticoagulation may be considered for 1-3 months until ventricular function recovers, as suggested by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1. Initial treatment often begins with intravenous unfractionated heparin or subcutaneous low molecular weight heparin (such as enoxaparin 1mg/kg twice daily) as a bridge to oral therapy. The rationale for anticoagulation is that the akinetic or dyskinetic apex in Takotsubo creates blood stasis, increasing thrombus formation risk and subsequent embolic events. Since Takotsubo typically resolves within weeks to months, anticoagulation is usually temporary until ventricular function normalizes. Regular echocardiographic follow-up is essential to assess recovery and guide anticoagulation duration. Some key points to consider when managing patients with Takotsubo cardiomyopathy include:
• Avoiding the administration of nitroglycerin in the presence of left ventricular outflow tract obstruction (LVOTO) 1
• Using QT-interval prolonging drugs cautiously in the acute phase due to the risk of inducing torsades de pointes or ventricular tachycardia and fibrillation 1
• Considering the use of a wearable defibrillator (life vest) in cases of excessive prolongation of the QT interval or life-threatening ventricular arrhythmias 1
• Using a temporary transvenous pacemaker for patients with hemodynamically significant bradycardia 1

From the Research

Indications for Anticoagulation in Takotsubo

• The formation of left ventricular (LV) thrombi is a complication in Takotsubo syndrome (TTS), occurring in 1.3-5.3% of patients 2.
• Risk factors for thrombi formation include apical TTS, elevated levels of C-reactive protein and troponine, thrombocytosis, persisting ST segment elevation, and right-ventricular involvement 2.
• Anticoagulation is recommended due to the high embolic risk associated with LV thrombi in TTS 2, 3.
• Atrial fibrillation and low ejection fraction on presentation are independent risk factors for the development of thromboembolic events in patients with TCM 4.
• The management of TTS includes anticoagulants, and heparin should be started in patients with thromboembolism, with bridging to warfarin for up to three months to prevent systemic emboli 5.
• Elevated serum levels of C-reactive protein and thrombocytosis may indicate a higher risk of thrombus formation in TTS 6.
• Treatment with low molecular weight heparin (LMWH) can lead to resolution of thrombus in patients with TTS 6.

Thromboembolic Events

• Thromboembolism is a common complication in the acute phase of Takotsubo cardiomyopathy, occurring in 14% of patients in one study 3.
• Thromboembolic events can occur despite therapeutic anticoagulation, highlighting the need for close monitoring and consideration of cardiac surgery in high-risk patients 2.
• The incidence of LV thrombus in TTS is estimated to be around 8% based on echocardiography findings 6.

Anticoagulation Therapy

• Anticoagulation therapy should be performed in all patients with TTS until wall motion abnormalities improve 3.
• The use of anticoagulants, such as heparin and warfarin, is recommended in the management of TTS to prevent systemic emboli 5.
• Low molecular weight heparin (LMWH) can be effective in resolving thrombus in patients with TTS 6.