What are the signs, symptoms, and management of Takotsubo (stress cardiomyopathy) syndrome?

Takotsubo Syndrome: Signs and Symptoms

Takotsubo syndrome presents with chest pain and dyspnea that are clinically indistinguishable from acute myocardial infarction, occurring predominantly in postmenopausal women following emotional or physical stress, with ECG showing ST-segment elevation or T-wave abnormalities and cardiac biomarker elevation despite absence of obstructive coronary disease. 1

Clinical Presentation

Primary Symptoms

• Chest pain is the most common presenting symptom, occurring in 77% of patients 2
• Dyspnea (shortness of breath) occurs in approximately 32% of patients 2
• Symptoms are triggered by preceding emotional stress (29%) or physical stress (48%) in the majority of cases 2

Patient Demographics

• Postmenopausal women comprise 90% of cases, with mean age of 75 years 2
• Female sex carries an odds ratio of 29.0-163.7 for developing Takotsubo syndrome 1
• Male patients have up to three-fold increased mortality and worse outcomes when affected 1

Electrocardiographic Findings

Acute Phase ECG Changes

• ST-segment elevation is present in 42% of patients at initial presentation, mimicking STEMI 2
• ST/T wave abnormalities occur in 58% of patients 2
• The initial ECG is abnormal in most patients, typically demonstrating ischemic ST-segment elevation, T-wave inversion, or both 1

Temporal Evolution of ECG

• ST-segment elevation (if present) resolves first 1
• Progressive T-wave inversion develops over several days 1
• QT interval prolongation occurs and persists for days to weeks 1
• Complete resolution of T-wave inversion and QT prolongation occurs gradually over days to weeks 1

ECG Pattern Specificity

• ST-segment elevation centers on precordial leads V2-V5 and limb leads II and aVR 1
• ST-segment elevation in lead V1 is less pronounced in Takotsubo compared to anterior STEMI 1
• ST-segment elevation limited to inferior leads (II, III, aVF) is distinctly uncommon in Takotsubo 1

Cardiac Biomarkers

• Mild to moderate troponin elevation occurs in most patients 3, 2
• Troponin levels are typically less elevated than would be expected for the extent of wall motion abnormalities 3
• Cardiac enzyme elevation is distinct but not as pronounced as in acute myocardial infarction 2

Echocardiographic Findings

Wall Motion Abnormalities

• Apical ballooning with preserved basal function is the hallmark finding 3, 4
• The left ventricle assumes a characteristic "takotsubo" (octopus trap) shape during systole 3
• Transient left ventricular dysfunction with regional wall motion abnormalities extending beyond a single coronary territory 1

Associated Findings

• Right ventricular involvement occurs in some patients and predicts worse outcomes 1
• Mitral regurgitation (14-25% of cases) may be present 1
• Left ventricular ejection fraction is typically reduced, often <45% 1

In-Hospital Complications

Frequent Complications (>10%)

• Acute heart failure occurs in 12-45% of patients 1
• Left ventricular outflow tract obstruction develops in 10-25% 1
• Mitral regurgitation affects 14-25% 1
• Cardiogenic shock complicates 6-20% of cases 1
• Atrial fibrillation occurs in 5-15% 1

Moderate Complications (2-6%)

• Cardiac arrest in 4-6% 1
• Atrioventricular block in approximately 5% 1
• Tachyarrhythmias in 2-5% 1
• Bradyarrhythmias in 2-5% 1

Rare but Serious Complications (<2%)

• Left ventricular thrombus formation in 2-8% 1
• Torsades de pointes in 2-5% 1
• In-hospital death in 1-4.5% 1
• Ventricular tachycardia/fibrillation in approximately 3% 1

Diagnostic Predictors: InterTAK Score

High-Probability Features (≥70 points indicates high probability)

• Female sex: 68 points (OR 29.0-163.7) 1
• Emotional trigger: 65 points (OR 20.3-205.8) 1
• Absence of ST-segment depression: 72 points (OR 31-16.8) 1
• Physical trigger: 8.7 points (OR 4.6-17.3) 1
• Psychiatric disorders: 7.0 points (OR 3.1-15.5) 1
• Neurologic disorders: 4.9 points (OR 2.2-11.3) 1
• QTc prolongation: 2.8 points (OR 1.3-5.7) 1

Poor Prognostic Indicators

Acute Phase Risk Factors

• Physical trigger (rather than emotional) predicts worse outcomes 1
• Male gender carries up to three-fold increased mortality 1
• Initial troponin >10× upper reference limit 1
• Admission LVEF <45% 1
• Acute neurologic or psychiatric diseases 1

Hemodynamic Predictors

• High heart rate at presentation 1
• Low systolic blood pressure 1
• Right ventricular involvement independently predicts acute heart failure and mortality 1

Critical Diagnostic Pitfall

Despite symptom resolution and functional recovery, urgent coronary angiography is mandatory because ECG and clinical overlap with STEMI makes differentiation impossible without angiography 1. The diagnosis cannot be confirmed until absence of obstructive coronary disease is documented and complete recovery of left ventricular function occurs, typically within 1-4 weeks 5, 4.