What are the treatment options for Takotsubo (stress) cardiomyopathy?

Treatment Options for Takotsubo Cardiomyopathy

ACE inhibitors or ARBs should be the primary treatment for all variants of Takotsubo cardiomyopathy (TTS) as they are associated with improved survival and reduced recurrence rates. 1

Initial Management

Acute Phase Treatment

• Supportive care is the cornerstone of management as most cases are self-limiting 1, 2
• For hemodynamically unstable patients:
  • Consider mechanical circulatory support (intra-aortic balloon pump or VA-ECMO) for cardiogenic shock refractory to other treatments 1
  • Use vasodilators (phentolamine and/or nitrates) for coronary vasospasm from sympathomimetic triggers 1
• Anticoagulation:
  • IV/subcutaneous heparin for patients with severe LV dysfunction and apical ballooning due to risk of LV thrombus 1
  • Full anticoagulation for patients with confirmed LV thrombi 1

First-Line Pharmacological Therapy

• ACE inhibitors or ARBs - recommended by European Society of Cardiology and should be continued long-term 1, 2
• Aspirin and statins - for patients with concomitant coronary atherosclerosis 1
• Anticoagulation - as indicated above for high-risk patients 1

Special Considerations

Left Ventricular Outflow Tract Obstruction (LVOTO)

• Occurs in approximately 20% of cases 1
• Requires careful assessment and management
• Avoid inotropes and vasodilators which may worsen LVOTO 1

Arrhythmia Management

• Monitor for ventricular tachycardia, ventricular fibrillation, and QT prolongation 1
• Treat arrhythmias according to standard protocols

Beta-Blockers

• While commonly used in clinical practice, the evidence for beta-blockers in TTS is mixed 3, 4
• The most recent evidence from 2025 suggests they may have a role in acute management and prevention of recurrence 3, though earlier research from 2008 found no significant benefit 4

Follow-Up Care

• Follow-up imaging at 1-4 weeks to confirm resolution of wall motion abnormalities 1
• Continue ACE inhibitors or ARBs long-term to reduce recurrence risk 1, 2
• Monitor for recurrence (approximately 5% of patients) 1
• Consider psycho-cardiologic rehabilitation for patients with psychiatric comorbidities 1

Prognosis

• Approximately 95% of patients make a full recovery 1, 2
• LV function typically normalizes within 3-4 weeks 1
• Despite initial beliefs that TTS was benign, recent evidence shows morbidity and mortality rates comparable to those of acute coronary syndrome 1

Common Pitfalls to Avoid

1. Misdiagnosis as acute myocardial infarction - TTS presents with similar ECG and biomarker indications 2, 5
2. Inappropriate use of inotropes - may worsen LVOTO in affected patients 1
3. Missing LV thrombus - careful assessment and appropriate anticoagulation is essential 1
4. Overlooking the need for long-term therapy - ACE inhibitors or ARBs should be continued to prevent recurrence 1
5. Failing to recognize complications - despite being generally self-limiting, TTS can lead to serious complications including cardiogenic shock 1, 6