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. Some key points to consider when managing Takotsubo cardiomyopathy include:
• The use of anticoagulant therapy for LV thrombi, as recommended in the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1
• The consideration of prophylactic anticoagulation to prevent LV thrombi, as stated in the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1
• The importance of individualized treatment, taking into account the patient's specific clinical presentation and risk factors
• The need for careful monitoring and follow-up to assess the resolution of thrombus and recovery of left ventricular function. Initial treatment often begins with intravenous heparin or subcutaneous low molecular weight heparin (such as enoxaparin 1mg/kg twice daily) before transitioning to oral therapy. The rationale for anticoagulation stems from the risk of thromboembolism due to blood stasis in the akinetic or dyskinetic ventricular segments, particularly the apex which is characteristically affected in Takotsubo. Since most cases of Takotsubo resolve within weeks to months, anticoagulation is typically temporary and can be discontinued once ventricular function normalizes and any thrombus resolves, as confirmed by follow-up echocardiography.

From the Research

Indications for Anticoagulation in Takotsubo

• The decision to initiate anticoagulation in patients with Takotsubo syndrome is based on the risk of thromboembolic events, which can be as high as 14.3% 2.
• Risk factors for thromboembolic events in Takotsubo cardiomyopathy include apical TTS, elevated levels of C-reactive protein and troponine, thrombocytosis, persisting ST segment elevation, and right-ventricular involvement 3.
• Atrial fibrillation and low ejection fraction on presentation are independent risk factors for the development of thromboembolic events in patients with Takotsubo cardiomyopathy 4.
• Anticoagulation therapy is recommended for all patients with Takotsubo cardiomyopathy until wall motion abnormalities improve, as thromboembolism is a common complication in the acute phase of the disease 5.
• The management of patients with Takotsubo syndrome and thromboembolism includes the initiation of heparin and bridging to warfarin for up to three months to prevent systemic emboli 6.

Patient Selection for Anticoagulation

• Patients with Takotsubo cardiomyopathy who are at high risk of thromboembolic events, such as those with apical TTS, atrial fibrillation, or low ejection fraction, should be considered for anticoagulation therapy 3, 4.
• Patients who have already developed thromboembolic events, such as cardioembolic stroke, should be treated with anticoagulation to prevent further events 5, 6.
• The decision to initiate anticoagulation should be individualized based on the patient's risk factors and the presence of complications, such as cardiogenic shock or left ventricular outflow tract obstruction 6.

Monitoring and Treatment

• Patients with Takotsubo cardiomyopathy who are receiving anticoagulation therapy should be monitored closely for signs of thromboembolic events, such as stroke or systemic emboli 3, 5.
• Echocardiography should be used to monitor for the development of left ventricular thrombi, which can increase the risk of thromboembolic events 3, 2.
• The treatment of thromboembolic events in patients with Takotsubo cardiomyopathy should include anticoagulation therapy, as well as other supportive measures, such as inotropic agents or cardiac surgery, as needed 6.