What is Takotsubo (stress) cardiomyopathy?

From the Guidelines

Takotsubo cardiomyopathy should be treated with supportive care, including medications like ACE inhibitors, beta-blockers, and aspirin, as well as identification and management of triggering stressors, to reduce morbidity and mortality and improve quality of life. The condition, also known as stress cardiomyopathy or broken heart syndrome, is a temporary heart condition that mimics a heart attack but is caused by emotional or physical stress rather than blocked coronary arteries 1. It occurs when part of the heart muscle, typically the left ventricle, temporarily enlarges and weakens, taking on a balloon-like shape resembling a Japanese octopus trap called "takotsubo" 1.

Key Considerations

• Treatment focuses on supportive care while the heart recovers, usually including medications like ACE inhibitors (such as lisinopril 5-20mg daily), beta-blockers (such as metoprolol 25-100mg twice daily), and aspirin (81mg daily) 1.
• These medications help reduce strain on the heart and prevent complications, and patients should be treated with conventional agents as otherwise indicated if hemodynamically stable 1.
• Anticoagulation should be administered in patients who develop LV thrombi 1.
• Catecholamines may be used for patients with symptomatic hypotension if outflow tract obstruction is not present, but should be used cautiously 1.
• The use of IABP is reasonable for patients with refractory shock 1.

Recurrence and Long-Term Management

• Patients who survive the initial event have a second event in approximately 5% of cases, mostly occurring 3 weeks to 3.8 years after the first event 1.
• Recurrent TTS afflicts men and women and may occur at any age, including in childhood 1.
• Patients should be monitored long-term, and identification and management of triggering stressors, possibly with psychological support, is important during recovery 1.

From the Research

Definition and Classification of Takotsubo Cardiomyopathy

• Takotsubo cardiomyopathy (TTC) is a clinical condition of transient acute heart failure correlated to regional wall motion abnormalities extending beyond the distribution of a single epicardial coronary artery 2.
• It is classified into four major types: apical, basal, mid-ventricular, and focal 2.
• Takotsubo syndrome (TTS) is also known as Takotsubo cardiomyopathy, and is a transient left ventricular wall dysfunction that is often triggered by physical or emotional stressors 3.

Pathogenesis and Clinical Course

• Sympathetic nerve stimulation and catecholamine storm are the main players in the pathogenesis of TTC 2.
• The clinical course of disease is generally benign but it may end with life-threatening complications 2.
• Catecholamine surge related to emotional distress seems to play a major role in the pathogenesis of this cardiomyopathy, rendering TC a type of neurocardiological disorder that manifests as acute but reversible heart failure 4.

Diagnosis and Diagnostic Tools

• Coronary angiography, left ventriculogram, transthoracic echocardiography, and cardiac magnetic resonance imaging (CMR) are the main tools for making diagnosis 2.
• A diagnosis of TTS can be made using Mayo diagnostic criteria 3.

Management and Treatment

• The initial management of TTS includes dual antiplatelet therapy, anticoagulants, beta-blockers, angiotensin-converting enzyme inhibitors or aldosterone receptor blockers, and statins 3.
• Treatment is usually provided for up to three months and has a good safety profile 3.
• Except for critical cases with hemodynamic instability and/or complications, the overall management is limited to conventional heart failure therapy 2.
• However, a study found that chronic treatment with beta-blockers, ACE-inhibitors, calcium channels blockers, and aspirin does not provide any benefit in patients with Takotsubo cardiomyopathy 5.
• Currently, there are no randomized controlled trials to support the use of beta blockers and angiotensin-converting enzyme inhibitors in the treatment of Takotsubo syndrome 6.

Complications and Prognosis

• Takotsubo syndrome has substantial morbidity and mortality, and can be challenging to distinguish from acute coronary syndrome 6.
• In TTS with complications such as cardiogenic shock, management depends on left ventricular outflow tract obstruction (LVOTO) 3.
• In patients without LVOTO, inotropic agents can be used to maintain pressure, while inotropic agents are contraindicated in patients with LVOTO 3.
• In TTS with thromboembolism, heparin should be started, and patients should be bridged to warfarin for up to three months to prevent systemic emboli 3.