What is the treatment for takotsubo (stress) cardiomyopathy?

Treatment of Takotsubo Cardiomyopathy

ACE inhibitors or ARBs should be initiated immediately and continued long-term as they are associated with improved survival and reduced recurrence, while beta-blockers may be used cautiously in the acute phase but have not demonstrated long-term benefit. 1

Acute Phase Management

Hemodynamically Stable Patients

Initial pharmacotherapy should include:

• ACE inhibitors or ARBs are the cornerstone of acute management, facilitating left ventricular recovery and improving 1-year survival 1, 2
• Beta-blockers may be reasonable until LVEF recovery given elevated catecholamine levels, though clinical trial evidence is lacking 1, 3, 2
  • Critical caveat: Use cautiously in patients with bradycardia or QTc >500 ms due to risk of pause-dependent torsades de pointes 1
• Diuretics for pulmonary edema 1, 2
• Aspirin as part of supportive care 2, 4

Medications to avoid:

• QT-prolonging drugs should be avoided entirely in the acute phase due to risk of torsades de pointes, ventricular tachycardia, and fibrillation 1, 3, 4
• Nitroglycerin should be avoided if LVOTO is present as it worsens the pressure gradient, though it can be useful for reducing LV filling pressures when LVOTO is excluded 1, 3

Hemodynamically Unstable Patients

For cardiogenic shock, the treatment algorithm is:

1. Promptly evaluate for LVOTO (occurs in ~20% of cases) using LV pressure recording during angiography or continuous wave Doppler echocardiography 1, 2

2. If LVOTO is absent:

   • Catecholamines may be administered for symptomatic hypotension 2, 4
   • However, catecholamines are associated with 20% mortality and should be used with extreme caution 1

3. If LVOTO is present or shock persists:

   • Intra-aortic balloon pump (IABP) is first-line therapy for cardiogenic shock 3, 4
   • Levosimendan (calcium-sensitizer) is the preferred alternative inotrope to catecholamines and may be safer 1, 3, 2
   • VA-ECMO for persistent cardiogenic shock or cardiac arrest unresponsive to maximal treatment 4

Anticoagulation Strategy

Anticoagulation decisions based on LV thrombus risk:

• Severe LV dysfunction with extended apical ballooning carries high thrombus risk 1
• Initiate IV/subcutaneous heparin when LV thrombus is detected or suspected 1, 2, 4
• Moderate-intensity warfarin (INR 2.0-3.0) for at least 3 months if acute LV thrombus identified 2
• Post-discharge oral anticoagulation or antiplatelet therapy may be considered on an individual basis 1

Arrhythmia Management

For life-threatening arrhythmias:

• Wearable defibrillator (life vest) for excessive QT prolongation or life-threatening ventricular arrhythmias 1, 4
• Temporary transvenous pacemaker for hemodynamically significant bradycardia 1, 4
• Implantable cardioverter-defibrillator is of uncertain value given reversibility of LV dysfunction and ECG abnormalities 1

Long-Term Management

The evidence strongly favors ACE inhibitors/ARBs over beta-blockers for long-term therapy:

• ACE inhibitors or ARBs are strongly recommended long-term as they are associated with improved survival at 1-year follow-up and lower prevalence of recurrence even after propensity matching 1, 2, 4
• Beta-blockers have shown no evidence of survival benefit for long-term use 1
• One-third of patients experienced TTS recurrence during beta-blockade, suggesting other receptors (such as alpha-receptors in coronary microcirculation) may be involved 1
• Aspirin and statins if concomitant coronary atherosclerosis is present 1, 4

Monitoring and Follow-Up

Serial echocardiography is essential:

• Perform serial echocardiography to monitor LV function recovery, which typically occurs within 1-4 weeks 3, 4
• Complete recovery of LV function must be documented to confirm the diagnosis 3, 4
• Monitor for new-onset atrial fibrillation, sinus node dysfunction, and AV block 2

Critical Pitfalls to Avoid

The most dangerous management errors:

• Never use catecholamine-based inotropes like dobutamine as first-line therapy as they may theoretically worsen takotsubo cardiomyopathy and are associated with 20% mortality 1, 3
• Never administer nitroglycerin if LVOTO is present as it worsens the pressure gradient 1, 3
• Do not rely on beta-blockers for recurrence prevention as they have not demonstrated this benefit 1, 4
• Avoid QT-prolonging medications entirely in the acute phase 1, 3, 4