Initial Treatment for Takotsubo Syndrome
Start ACE inhibitors or ARBs immediately as the cornerstone of acute management, as they facilitate left ventricular recovery and improve 1-year survival. 1, 2
Immediate Assessment and Risk Stratification
Evaluate for Left Ventricular Outflow Tract Obstruction (LVOTO)
- Promptly assess all patients with cardiogenic shock for LVOTO, which occurs in approximately 20% of cases, particularly those with apical ballooning. 3, 1
- Perform LV pressure recording during angiography by carefully retracting the pigtail catheter from the LV apex beyond the aortic valve, or use continuous wave Doppler echocardiography. 3, 1
- Serial Doppler studies should be considered if catecholamines are being used, as LVOTO can evolve. 3
Hemodynamically Stable Patients
First-Line Pharmacotherapy
- Initiate ACE inhibitors or ARBs immediately—these are the most important medications for both acute and long-term management. 1, 4, 2
- Add diuretics for pulmonary edema. 3, 1, 4
- Consider beta-blockers cautiously until LVEF recovery, though evidence supporting their use is limited. 3, 1, 4
- Administer aspirin as part of supportive care. 1, 2
Critical Medications to Avoid
- Eliminate all QT-prolonging drugs immediately—they increase risk of torsades de pointes, ventricular tachycardia, and fibrillation. 3, 1, 4
Hemodynamically Unstable Patients Without LVOTO
Inotropic Support Strategy
- If LVOTO is absent and hypotension persists, catecholamines may be administered, but use with extreme caution as they are associated with 20% mortality. 3, 1, 4
- Levosimendan (calcium-sensitizer) is the preferred alternative inotrope and may be safer than catecholamines. 3, 1, 4, 2
- Never use nitroglycerin if LVOTO is present—it worsens the pressure gradient. 3, 1, 4
- Nitroglycerin is useful to reduce LV and RV filling pressures only when LVOTO has been excluded. 3, 4
Hemodynamically Unstable Patients With LVOTO or Cardiogenic Shock
Mechanical Circulatory Support
- Intra-aortic balloon pump (IABP) is first-line therapy for cardiogenic shock, especially when LVOTO is present. 1, 4
- Beta-blockers may improve LVOTO but are contraindicated in acute severe heart failure with low LVEF and hypotension. 3
- Ivabradine (If channel inhibitor) may benefit patients with LVOTO, though evidence is unproven. 3
Anticoagulation Strategy
Thrombus Prevention
- Initiate IV or subcutaneous heparin immediately in patients with severe LV dysfunction and extended apical ballooning due to high LV thrombus risk. 3, 1, 2
- Consider moderate-intensity warfarin (INR 2.0-3.0) for at least 3 months if acute LV thrombus is identified. 1, 2
- Post-discharge oral anticoagulation or antiplatelet therapy should be considered on an individual basis. 3
Arrhythmia Management
Monitoring and Device Therapy
- Monitor for new-onset atrial fibrillation, sinus node dysfunction, and AV block. 1, 2
- Consider a wearable defibrillator (life vest) for excessive QT prolongation or life-threatening ventricular arrhythmias. 3, 1
- Place a temporary transvenous pacemaker for hemodynamically significant bradycardia. 3, 1
- Implantable cardioverter-defibrillators are of uncertain value given the reversibility of LV dysfunction and ECG abnormalities. 3, 1
Common Pitfalls to Avoid
- Never use catecholamine-based inotropes like dobutamine as first-line therapy—they may worsen the condition and carry 20% mortality. 1, 4
- Never administer nitroglycerin without first excluding LVOTO. 3, 1, 4
- Do not use beta-blockers in patients with bradycardia or QTc >500 ms. 3, 1, 4
- Avoid all QT-prolonging medications in the acute phase. 3, 1, 4