How is Takotsubo (stress cardiomyopathy) syndrome managed?

Management of Takotsubo Syndrome (Stress Cardiomyopathy)

Initial Management

The primary treatment for all variants of takotsubo cardiomyopathy (TTS) should be ACE inhibitors or ARBs, which are associated with improved survival and reduced recurrence rates. 1

Initial management should follow this algorithm:

1. Supportive care for hemodynamic stability
2. Rule out acute coronary syndrome through coronary angiography
3. Initiate pharmacological therapy:
   • ACE inhibitors or ARBs (first-line)
   • Aspirin and statins if concomitant coronary atherosclerosis is present
   • Anticoagulation with heparin for severe LV dysfunction and apical ballooning
   • Full anticoagulation for patients with LV thrombi

Management of Complications

For patients with complications, implement the following measures:

• Cardiogenic shock: Consider mechanical circulatory support (intra-aortic balloon pump or VA-ECMO) if refractory to other treatments 1
• Coronary vasospasm: Administer vasodilators (phentolamine and/or nitrates) 1
• Left ventricular outflow tract obstruction (occurs in ~20% of cases): Avoid inotropes and vasodilators; consider beta-blockers and fluid resuscitation 1
• Arrhythmias: Standard management for ventricular tachycardia, ventricular fibrillation, and QT prolongation 1
• Thromboembolism: Anticoagulation for patients with severe LV dysfunction or detected thrombi 1

Special Considerations

• Psychiatric comorbidities: Implement psycho-cardiologic rehabilitation 1
• Hyperthermia: Apply rapid external cooling if present 1

Diagnostic Criteria

Diagnosis requires:

• Transient left ventricular dysfunction
• Absence of obstructive coronary artery disease
• New ECG abnormalities or modest elevation in cardiac troponin
• Absence of pheochromocytoma and myocarditis 1

The InterTAK Diagnostic Score can guide management:

• Score ≥70: High probability of TTS
• Score <70: Proceed with coronary angiography 1

Follow-up Care

1. Imaging follow-up: Perform echocardiography at 1-4 weeks to confirm resolution of wall motion abnormalities 1
2. Long-term medication: Continue ACE inhibitors or ARBs long-term to prevent recurrence 1, 2
3. Monitor for recurrence: Approximately 5% of patients experience recurrence 1

Prognosis

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

Important Caveats

• TTS predominantly affects postmenopausal women (90% of patients) with a mean age of 66.8 years 1
• Cardiac troponin is typically modestly elevated, disproportionately low compared to the extensive wall motion abnormalities 1
• Avoid inotropic agents in patients with LVOTO as they may worsen obstruction
• The condition is usually triggered by emotional or physical stressors, so addressing these underlying triggers is important for prevention of recurrence