From the Guidelines
Management of Takotsubo (stress) cardiomyopathy involves supportive care with conventional agents, such as beta blockers, ACE inhibitors, and diuretics, as indicated.
Key Management Strategies
- Imaging studies, such as ventriculography, echocardiography, or magnetic resonance imaging, should be performed to confirm or exclude the diagnosis of stress (Takotsubo) cardiomyopathy 1.
- Conventional agents, including beta blockers, ACE inhibitors, aspirin, and diuretics, should be used as otherwise indicated if the patient is hemodynamically stable 1.
- Catecholamines may be used for patients with symptomatic hypotension if outflow tract obstruction is not present, but should be used cautiously due to the potential risk of pause-dependent torsades de pointes 1.
- Anticoagulation should be administered in patients who develop LV thrombi, and prophylactic anticoagulation may be considered to inhibit the development of LV thrombi 1.
- Mechanical circulatory support, including intra-aortic balloon pump, may be used for patients with refractory shock 1.
Special Considerations
- Outflow tract obstruction should be promptly evaluated for in patients with cardiogenic shock, particularly those with apical ballooning, and beta blockers may improve LVOTO, but are contraindicated in acute and severe heart failure with low LVEF, hypotension, and in those with bradycardia 1.
- Levosimendan, a Ca2+-sensitizer, may be used safely and effectively in TTS as an alternative inotrope to catecholamine agents 1.
- Vasodilators, including nitrates and α-adrenergic receptor antagonists, may be used to treat coronary vasospasm in patients with sympathomimetic poisoning 1.
From the Research
Management of Takotsubo Cardiomyopathy
The management of Takotsubo cardiomyopathy is largely supportive and should be tailored to the patient's individual needs based on the severity of presentation 2. The treatment approach may vary depending on the underlying stressor and the variant of cardiomyopathy.
Treatment Principles
- Treatment is usually empirical and supportive, via extrapolation of therapeutic principles worked out for other cardiovascular pathologies 3.
- The initial management may include dual antiplatelet therapy, anticoagulants, beta-blockers, angiotensin-converting enzyme inhibitors or aldosterone receptor blockers, and statins 4.
- Angiotensin-converting enzyme inhibitors have been shown to reduce the recurrence of Takotsubo cardiomyopathy 2, 5.
- In complicated cases, inotropes are preferred over vasopressors, except in the presence of left ventricular outflow tract obstruction, in which medical therapy is limited to fluids administration and beta-blockers 5.
Management of Complications
- In patients with cardiogenic shock, management depends on left ventricular outflow tract obstruction (LVOTO) 4.
- In patients with thromboembolism, heparin should be started, and patients should be bridged to warfarin for up to three months to prevent systemic emboli 4.
- Mechanical supports are reserved for refractory hemodynamically unstable cases 5.
Follow-up and Recurrence Prevention
- Long-term risks exist, including the risk for recurrent Takotsubo cardiomyopathy 2.
- Oral vitamin K antagonist can benefit patients at high thrombo-embolic risk for up to 3 months 5.
- Considerations pertaining to the recurrence of Takotsubo cardiomyopathy should be taken into account during follow-up 3.