What is Takotsubo (stress) cardiomyopathy?

From the Guidelines

Takotsubo cardiomyopathy should be treated with supportive care, including medications like beta-blockers, ACE inhibitors, and diuretics, to reduce heart workload and improve outcomes, as recommended by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1.

Key Considerations

• The condition is typically triggered by intense emotional or physical stress, and treatment focuses on supportive care while the heart recovers.
• Imaging with ventriculography, echocardiography, or magnetic resonance imaging should be performed to confirm or exclude the diagnosis of stress (Takotsubo) cardiomyopathy, as recommended by the 2014 AHA/ACC guideline 1.
• Patients with symptomatic hypotension may be treated with catecholamines if outflow tract obstruction is not present, according to the 2014 AHA/ACC guideline 1.
• The use of beta blockers and alpha-adrenergic agents may be considered in patients with outflow tract obstruction, as suggested by the 2014 AHA/ACC guideline 1.

Management and Outcomes

• The international expert consensus document on Takotsubo syndrome published in 2018 recommends that patients with cardiogenic shock, particularly those with apical ballooning, should be promptly evaluated for the presence of LVOTO 1.
• The document also suggests that the Ca2+-sensitizer levosimendan could be used safely and effectively in TTS as an alternative inotrope to catecholamine agents 1.
• Recurrence of Takotsubo syndrome occurs in approximately 5% of cases, mostly occurring 3 weeks to 3.8 years after the first event, as reported in the 2018 international expert consensus document 1.

Treatment Priorities

• The primary goal of treatment is to reduce heart workload and improve outcomes, with a focus on supportive care and medications like beta-blockers, ACE inhibitors, and diuretics.
• Medical monitoring is essential during recovery to prevent complications such as heart failure, arrhythmias, or blood clots.
• The use of anticoagulation should be considered in patients who develop LV thrombi, as recommended by the 2014 AHA/ACC guideline 1.

From the Research

Definition and Causes of Takotsubo

• Takotsubo cardiomyopathy, also known as broken heart syndrome, apical ballooning syndrome, or stress cardiomyopathy, occurs when a stressful emotional or physical event causes the left ventricle of the heart to dilate, leading to acute heart failure 2.
• The syndrome is often triggered by physical or emotional stressors, and it is characterized by a transient left ventricular wall dysfunction 3.
• Takotsubo syndrome is a neurocardiac condition that is among the most dramatic manifestations of psychosomatic disorders, and it can be precipitated by regions of left ventricular hypokinesis or akinesis 4.

Diagnosis and Misdiagnosis

• The signs and symptoms of Takotsubo cardiomyopathy are similar to acute myocardial infarction, and it often goes undiagnosed until coronary angiography is performed and reveals no blockage 2.
• A diagnosis of Takotsubo syndrome can be made using Mayo diagnostic criteria, and it is often misdiagnosed as acute coronary syndrome 3.
• The clinical presentation of Takotsubo syndrome can be indistinguishable from a myocardial infarction, and it accounts for up to 2% of Acute Coronary Syndrome (ACS) presentations 5.

Treatment and Management

• Treatment for Takotsubo cardiomyopathy is largely supportive, and angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) may reduce the likelihood of recurrent episodes 2.
• The initial management of Takotsubo syndrome includes dual antiplatelet therapy, anticoagulants, beta-blockers, angiotensin-converting enzyme inhibitors or aldosterone receptor blockers, and statins 3.
• The effect of aspirin in Takotsubo syndrome is still being studied, and a systematic review and meta-analysis is being conducted to evaluate the impact of long-term maintenance treatment of aspirin in Takotsubo syndrome 6.

Prognosis and Outcome

• The prognosis for Takotsubo cardiomyopathy is very good, with about 95% of patients making a full recovery 2.
• Recent studies report that the prognosis for Takotsubo syndrome is similar to that for acute myocardial infarction 4.
• The incidence of Takotsubo syndrome appears to be increasing, particularly during the COVID-19 pandemic, with a 4.5-fold increase in incidence even in individuals without severe acute respiratory syndrome coronavirus 2 infection 4.