Takotsubo Cardiomyopathy: A Comprehensive Overview
Takotsubo cardiomyopathy (TCM) is an acute, usually reversible left ventricular dysfunction characterized by regional wall motion abnormalities in the absence of significant coronary artery disease, typically triggered by acute emotional or physical stress. 1
Definition and Characteristics
- Also known as stress-induced cardiomyopathy, broken heart syndrome, or apical ballooning syndrome
- First described in Japan in 1990 (the term "Tako-tsubo" refers to octopus catching pots used in Japan, which resemble the shape of the affected left ventricle) 1
- Accounts for approximately 2% of all patients admitted with suspected acute coronary syndrome 1
- Predominantly affects postmenopausal women (90% of cases), with a mean age of 66.8 years 1
Pathophysiology
The exact mechanism remains unclear, but evidence supports:
- Adrenergically mediated process with catecholamine surges in response to stress 1
- Higher β2-adrenergic receptor density in the ventricular apex making it more responsive to sympathetic stimuli 1
- Potential mechanisms include:
Clinical Presentation
Patients typically present with:
- Chest pain similar to acute coronary syndrome 1
- Acute dyspnea
- ECG changes mimicking myocardial infarction (ST-segment elevation or T-wave inversion) 1
- Mild elevation of cardiac enzymes (troponin) disproportionate to the extent of wall motion abnormality 1
- Symptoms often preceded by emotional or physical stressor 1
Diagnostic Features
Imaging Findings
- Classic pattern: Apical ballooning with hyperkinesis of the base of the heart 1
- Variant forms: Mid-ventricular involvement, basal involvement, or biventricular involvement 1
- Wall motion abnormalities typically involve multiple coronary territories 1
- Complete recovery of ventricular function within weeks is characteristic 1
Laboratory Findings
- Elevated cardiac biomarkers (troponin), but peak values substantially lower than in acute coronary syndrome 1
- Marked elevation of BNP/NT-proBNP, peaking 24-48 hours after symptom onset 1
- Slight increase in creatine kinase 1
Diagnostic Criteria
The InterTAK Diagnostic Score can help distinguish TCM from acute coronary syndrome, considering:
- Female sex
- Emotional or physical trigger
- Absence of ST-segment depression (except in lead aVR)
- Psychiatric or neurologic disorders
- QT prolongation 1
Management
Management is primarily supportive 2:
Heart failure management:
- Avoid traditional inotropes like dobutamine (may worsen condition due to catecholamine-mediated pathophysiology)
- Intra-aortic balloon pump is considered first-line mechanical support for severe cases
- VA-ECMO for refractory shock
Medication considerations:
- Beta-blockers should be used with caution due to potential negative inotropy
- ACE inhibitors or ARBs are associated with improved survival and lower recurrence rates
- Avoid QT-prolonging medications during the acute phase
- Anticoagulation with heparin recommended for patients with severe LV dysfunction due to risk of LV thrombus
Follow-up:
- Imaging at 1-4 weeks to confirm resolution of wall motion abnormalities
- Long-term ACE inhibitors or ARBs may be beneficial
- Consider addressing underlying psychological stressors in patients with recurrent episodes
Prognosis
- Generally favorable with approximately 95% of patients making full recovery 3
- Complete recovery of ventricular function typically occurs within 3-4 weeks 4
- Long-term follow-up reveals some morbidity and mortality (rate of death at 5.6% per patient-year) 1
- Recurrence rate is approximately 5% 2
Common Pitfalls and Caveats
- Misdiagnosis as acute coronary syndrome is common due to similar presentation
- Avoid traditional inotropes like dobutamine which may worsen the condition
- Assess for left ventricular outflow tract obstruction (occurs in ~20% of cases)
- Monitor for QT prolongation and ventricular arrhythmias
- Consider TCM in postmenopausal women presenting with chest pain after emotional or physical stress
- Coronary angiography is mandatory to rule out obstructive coronary artery disease 1