What is the treatment for Takotsubo (stress) cardiomyopathy?

Treatment for Takotsubo Cardiomyopathy

ACE inhibitors or ARBs are the first-line therapy for Takotsubo cardiomyopathy (TTS) as they are associated with improved survival and lower recurrence rates. 1 Management should be tailored based on hemodynamic status and complications.

Acute Phase Management

Initial Assessment

• Evaluate for left ventricular outflow tract obstruction (LVOTO) - occurs in ~20% of cases 1
• Assess for complications: heart failure, cardiogenic shock, arrhythmias
• Monitor QT interval (risk of torsades de pointes)

Medication Management

1. Heart Failure Treatment

   • ACE inhibitors or ARBs to facilitate LV recovery 2, 1
   • Diuretics for patients with pulmonary edema 2
   • Beta-blockers may be reasonable until LVEF recovery, but use with caution in:
     • Patients with bradycardia
     • QTc >500 ms (risk of torsades de pointes) 2
     • Patients with LVOTO (may worsen obstruction)

2. Cardiogenic Shock Management

   • Without LVOTO: Consider cautious use of inotropes
   • With LVOTO: Avoid catecholamines and nitroglycerin (worsen pressure gradient) 2
   • Consider mechanical circulatory support:
     • Intra-aortic balloon pump (IABP) for refractory shock
     • VA-ECMO in severe cases 1

3. Anticoagulation

   • IV/subcutaneous heparin for severe LV dysfunction with apical ballooning (risk of LV thrombus) 2
   • Full anticoagulation required if LV thrombi detected 1

4. Arrhythmia Management

   • Avoid QT-prolonging medications during acute phase 2
   • Consider wearable defibrillator for excessive QT prolongation or life-threatening ventricular arrhythmias 2
   • Temporary transvenous pacemaker for hemodynamically significant bradycardia 2

Long-term Management

Medication Therapy

• Continue ACE inhibitors or ARBs - associated with improved 1-year survival and lower recurrence rates 2, 1
• Beta-blockers - limited evidence for benefit in preventing recurrence 2, 3
  • One-third of patients experienced TTS recurrence despite beta-blockade 2
• Aspirin and statins - only if concomitant coronary atherosclerosis is present 2

Psychological Support

• Consider psycho-cardiologic rehabilitation for patients with comorbid psychiatric disorders (depression, anxiety) 2, 1
• Selective serotonin reuptake inhibitors (SSRIs) with cognitive behavioral therapy (CBT) may be beneficial in preventing recurrence in selected patients 4

Follow-up

• Imaging to confirm resolution of wall motion abnormalities (typically normalize within 1-4 weeks) 1
• Monitor for recurrence (occurs in approximately 5% of patients) 1

Important Caveats

• Despite common practice, no specific treatment has shown to improve mortality or recurrence rates in TTS 3
• Chronic treatment with beta-blockers, ACE-inhibitors, calcium channel blockers, and aspirin has not demonstrated significant benefits in improving LV function or hospitalization time in some studies 5
• Pretreatment with low-dose beta-blockers does not affect the severity of TTS presentation 6
• TTS can mimic acute coronary syndromes, including stent thrombosis after PCI, requiring careful differential diagnosis 7